Chromosomal Anomaly denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Tobii Dynavox I-110 with Snap + Core First speech-generating device (SGD). The American Speech-Language-Hearing Association (ASHA) notes that communication services and supports should be based on individual communication needs, and should be evaluated, planned, and provided by an interdisciplinary team with expertise in communication and language form, content, and function, as well as in augmentative and alternative communication (AAC). Brady and colleagues report that individuals with disabilities should be able to access functioning AAC and other AT (assistive technology) services and devices at all times. Current medical literature supports the provision of an AAC device for individuals with disabilities who have been evaluated and found capable of using such a device.

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for genomic exome sequencing analysis (CPT 81415 and 81416). This patients genetic condition, 4q deletion syndrome, is a phenotypically variable syndrome with a wide range of clinical presentations. Specific abnormalities are associated with terminal deletions, including cleft palate and congenital heart disease. Fogel and colleagues noted that clinical exome sequencing “is rapidly becoming the new standard for sequencing in genetic diagnostics, as all 21,000 genes in the human genome can be evaluated in an essentially unbiased manner.” The authors noted that in instances where phenotypic presentation does not yield a diagnosis, rather than embarking on a series of diagnostic tests, “exome sequencing could abbreviate or stop the diagnostic testing cascade by establishing the specific r…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for 10 additional supervision hours over a six-month period (for a total of 100 supervision hours over a six-month period), one additional hour per week direct applied behavior analysis (ABA) services (for a total of 16 hours per week direct ABA services), and/or potty training to be included in the ABA therapy. The Council of Autism Service Providers (CASP) and ABA Coding Coalition guidelines provide insight into the level of support for treatment of this patient’s autism and associated delays. The CASP highlights that for ABA to be medically necessary, “A developmentally appropriate ABA assessment process must identify strengths and weaknesses across domains and potential barriers to progress.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for 10 additional supervision hours over a six-month period (for a total of 100 supervision hours over a six-month period), one additional hour per week direct applied behavior analysis (ABA) services (for a total of 16 hours per week direct ABA services), and/or potty training to be included in the ABA therapy. The Council of Autism Service Providers (CASP) and ABA Coding Coalition guidelines provide insight into the level of support for treatment of this patient’s autism and associated delays. The CASP highlights that for ABA to be medically necessary, “A developmentally appropriate ABA assessment process must identify strengths and weaknesses across domains and potential barriers to progress.

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 chromosomal anomaly, then check the rights and deadlines that apply to your plan.