Blood Clot: when insurers say no, reviewers often say yes

Where the denial was overturned

The enrollee requested reimbursement for the gene test, Prothrombin G20210A (Factor II) mutation testing. The enrollee has a past medical history of a right acoustic neuroma, that was surgically resected. She has a history of migraines, which worsened after pregnancy. The enrollee previously utilized hormonal therapy for her migraines. A magnetic resonance venography (MRV) of the head showed filling defects in the right sigmoid sinus, concerning for thrombosis. Her neurologist recommended further evaluation in the neurointerventional radiology clinic. Hypercoagulable labs were drawn and the treatment plan included an angiogram and lumbar puncture to determine the severity and amount of clot/clots in her brain. However, her physician believed if the enrollee had a clotting disorder, these invasive tests, which carry risk of death, would be potentially unnecessary.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prothrombin (Factor II) G20210A gene mutation testing (CPT 81240). Stroke is caused by one of several pathophysiologic processes involving the blood vessels of the brain. The process may be intrinsic to the vessel, as in thrombosis seen in a hypercoagulable state. Stroke evaluation involves brain imaging, cardiac testing, and laboratory studies. The records provided for review document that this patient underwent a comprehensive neurological evaluation and patent foramen ovale closure. Despite the exhaustive work-up and medical evaluations, the patient sustained a subsequent stroke and etiology remained cryptogenic. Coinciding with the patient’s brain ischemia there was diagnosis of unprovoked pulmonary embolism.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for testing for F5 Coagulation Factor V Anal Leiden Variant and F2 Gene Analysis 20210 G>A Variant. Most patients who present with venous thromboembolism (VTE) do not benefit from testing for hypercoagulable disorders. This is because in most patients with an initial episode of VTE, the identification of an inherited defect does not alter therapeutic or prophylactic anticoagulant management, nor has it been shown to reduce mortality or VTE recurrence. Although testing in select high-risk populations of patients with VTE leads to increased identification of hypercoagulable states, it infrequently alters the duration of anticoagulation or prevents VTE-related death.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for focused ultrasound ablation of uterine leiomyomata including magnetic resonance (MR) guidance. There are multiple studies documenting the safety and efficacy of magnetic resonance-guided focused ultrasound surgery (MRgFUS) in controlling symptoms due to fibroids. In this patient’s case, the use of MRgFUS is not indicated as some of the fibroids measure greater than 5 cm, which is reported in most of the published studies about the efficacy and safety of this procedure. Overall, the data about the effectiveness of MRgFUS in patients with fibroids measuring larger than 5 cm remains minimal. Moreover, some data suggest that larger fibroids measuring larger than 5 cm may require the application of multiple procedures.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for blood clot was denied, the published record says the denial is worth fighting.