Breathing Problem: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchoscopy with endobronchial ultrasound (EBUS), Ion Robot Navigation and/or approval of insertion of bronchial valve. For patients who have peripheral lung lesions that are difficult to reach such as apical lung lesions, electromagnetic navigation guidance is recommended if the equipment and expertise is available. As noted in the medical literature, Robot Navigation to guide bronchoscopy can provide higher yield with high sensitivity and specificity than conventional bronchoscopy. Complication rates such as pneumothorax are lower than traditional bronchoscopy with transthoracic needle aspiration. For further evaluation of this patient’s lung nodules, the requested Ion Robot Navigation is likely to be more beneficial with increased diagnostic yield as compared to standard therapy.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for transthoracic echocardiography under stress. In this case, the patient reported progressively worsening exercise intolerance and dyspnea on exertion. For a male patient between the ages of 50 and 59 with typical/definite anginal equivalent symptoms, the pretest probability of coronary disease is assessed as intermediate to high. Researchers report that in patients with suspected stable coronary artery disease (CAD), intermediate pretest probability, and preserved ejection fraction, stress imaging, such as stress echocardiography, is preferred as the initial test option.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a portable oxygen concentrator. Venous blood gases should not be used as an indication for portable oxygen concentrators. Furthermore, the subsequent chest computed tomography (CT) and pulmonary function tests argue against many potential causes of true hypoxemia in this patient. While carbon monoxide levels can cause a falsely elevated oxygen level from a pulse oximeter, the patient’s Raynaud’s syndrome could also be causing a falsely low level on pulse oximetry. As such, for this particular patient, a pulse oximeter is not an adequate test to determine oxygen content in the blood.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with bronchopulmonary dysplasia and congenital malformation of the lung. The patient underwent tracheostomy and gastrostomy procedures with tracheostomy decannulation. In a letter, the provider noted the patient was receiving nebulizer treatments and chest physiotherapy. In a letter, the provider noted the patient had a complex history including prematurity. The provider also noted that the patient had recently contracted influenza and required an increase in nursing care for overnight respiratory monitoring. The patient was noted to be ambulatory with a steady gait. The patient was taking food by mouth and tube feedings without difficulty. The patient’s tracheostomy stoma was not completely closed and was covered with a gauze dressing.

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 breathing problem was denied, the published record says the denial is worth fighting.