Bone Fracture Break: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that a patient has requested reimbursement for injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (e.g., great saphenous vein, accessory saphenous vein), same leg. As reported in the current medical literature pertaining to the use of the Varithena procedure, the procedure has been demonstrated to be useful in treating lower extremity varicose veins with a high degree of success. The Varithena procedure was evaluated in two pivotal trials with the primary goal of improvement in varicose vein symptoms, supported by its indications. Clinical trial efficacy also included improvement in the appearance of varicose veins and physiological response to treatment.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right hip, MRI of the pelvis, and/or MRI of the right shoulder. Per the American College of Radiology (ACR) guidelines, the requested MRI of the pelvis and right hip are medically necessary for further evaluation of this patient. The records document that the findings visualized on the patient’s prior MRI examination require repeat MRI studies and is consistent with the recommendations from the interpreting radiologist. Per the imaging characteristics, additional evaluation with MRI is appropriate to help determine whether the lesions are malignant (Nascimento, et al.). If the lesions have increased in size since the previous studies, then the patient’s clinical management will be impacted, and may support an indication for biopsy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone 10/325 and Flexeril.Findings: The physician reviewer found that the guidelines of the Federation of State Medical Boards state that, “continuation, modification or termination of opioid therapy for pain is contingent on the clinician’s evaluation of (1) evidence of the patient’s progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.” The Centers for Disease Control (CDC) guidelines for the prescribing of opioids for chronic pain noted that “clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation.

Findings: The physician reviewer found that The patient has a history of obesity, type two diabetes, asthma, lupus and chronic headache. A visit note dated 9/6/22, reported the patient sustained a right ankle fracture on 8/30/22. A visit note dated 12/16/22, stated the patient had lupus-related pain, right ankle pain, and endurance deficits that limit mobility. The patient has been treated with right ankle surgery in October 2022, physical therapy and has crutches and a manual wheelchair. Mobility with this durable medical equipment (DME) was unsuccessful. It was recommended the patient try a four-wheel walker. However, the patient has requested authorization and coverage for use of a group two power wheelchair to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community.

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 bone fracture break was denied, the published record says the denial is worth fighting.