Brain Tumor denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an 11-year-old male enrollee has requested authorization and coverage for SonoSite AV400 vein viewing system and Buzzy 4 Shots to perform laboratory testing for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that The submitted documentation supports the medical necessity of the requested equipment in this clinical setting. He was diagnosed with a brain tumor as an infant and has since been diagnosed with multiple recurrences, undergoing surgical resection, radiation therapy, and chemotherapy. Most recently, there was concern for tumor recurrence. According to his caregivers, it is difficult to perform phlebotomy on him because of blood vessel caliber. There may also be a component of obesity and history of frequent phlebotomy with resultant scarring.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the brain with and without contrast. According to the American College of Radiology (ACR) Appropriateness Criteria, in the setting of post-treatment surveillance of a patient with a known history of brain tumor, an MRI of the head without and with contrast is considered usually appropriate. An MRI of the brain with and without contrast is the primary and optimal modality for post-treatment surveillance in the setting of a known brain tumor. Due to excellent spatial resolution and high sensitivity, MRI is preferred for early detection of recurrence or additional complications.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel test (CPT codes 81321, 81235 and 81201) for evaluation of the enrollee, who has a history of brain tumor. Findings: The physician reviewer found that There is a lack of support for the services at issue in this clinical setting. FoundationOne is a molecular assay that explores the mutations of an individual’s cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician or yields a result that is reliably clinically beneficial. There are various nonrandomized studies exploring the value of molecular profiling but these studies are not convincing.

Nature of Statutory Criteria/Case Summary: An enrollee has requested continued skilled nursing facility (SNF) care including physical therapy, occupational therapy, and speech therapy for treatment of the enrollee’s medical condition status post tumor resection. Findings: The physician reviewer found that this patient’s records do not demonstrate that continued SNF care including physical therapy, occupational therapy, and speech therapy is medically necessary. There is a lack of evidence that the patient currently requires such SNF services as intravenous or enteral feeding, tracheotomy aspiration, suprapubic catheter care, or treatment of a stage 3 or greater decubitus ulcer, institution of a bowel/bladder training program, colostomy care or other skilled nursing need.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving brain tumor, then check the rights and deadlines that apply to your plan.