Cirrhosis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient was treated for alcohol withdrawal with a Librium taper. The patient has continued to complain of agitation, tremors, and irritability.

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography angiography (CTA) for evaluation of the enrollee’s end stage liver cirrhosis awaiting liver transplant. Findings: The physician reviewer found that the requested diagnostic procedure has been established as medically necessary for evaluation of the patient’s medical condition. CTA of the chest is a radiologic examination of the structures in the chest that allows the clinician to see highly detailed vascular anatomy. The American College of Cardiology (ACC) recommends coronary angiography prior to liver transplantation when the patient has greater than two risk factors due to increased risk of poor outcomes in the transplanted patient with significant coronary artery disease (Raval, et al).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.1 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient was treated for withdrawal during hospitalization and the records indicate that he has been able to remain sober. The patient’s withdrawal needs can be safely managed in a Level 3.1 setting.

The patient is a 57-year-old man with hepatitis C genotype 1 and cirrhosis. He has failed treatment with interferon and ribavirin due to side effects including bone marrow and psychiatric effects. He has a long list of complicating diagnoses including hypertension and cholelithiasis. The patient’s provider has recommended the patient begin treatment with ribavirin monotherapy. The Health Plan has denied authorization and coverage for the requested therapy on the basis it is not medically necessary for treatment of the patient’s medical condition.The issue of treatment failure and the benefit of ongoing therapy with interferon or ribavirin as a method to suppress inflammation has been addressed in the published guidelines of the American Association for the Study of Liver Disease.

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