Congenital Heart Dft 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 consultation with a cardiac electrophysiologist, magnetic resonance imaging (MRI) of the heart, electrocardiogram, and/or blood tests (thyroid stimulating hormone (TSH), T3, T4, TSH-thyroid stimulating immunoglobulin, N-terminal pro-B-type natriuretic peptide (Nt-proBNP), troponin T, and plasma ceramides). Based on the available documentation, the requested consultation with a cardiac electrophysiologist is indicated for further evaluation of this patient’s medical conditions. The patient’s clinical picture may be clearer with additional information about her brother’s condition.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for consultation with an endocrinologist.Singhi and Saini stated that syncope is not a disease in itself but a symptom of an underlying disorder; hence, children with syncope require assessment to exclude an underlying life-threatening cardiac or non-cardiac disorder. Syncope describes a sudden and brief transient loss of consciousness (TLOC) with postural failure due to cerebral global hypoperfusion. The term TLOC is used when the cause is either unrelated to cerebral hypoperfusion or is unknown.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for private duty nursing services (CPT G0300 – 4320 units, CPT G0162 – 48 units). At issue in this case is whether the requested private duty nursing services (CPT G0300 – 4320 units, CPT G0162 – 48 units) are medically necessary to treat the patient’s condition for any of the following:• to prevent disease, disability, and other health conditions or their progression;• to prolong life;• to promote physical and mental health and efficiency; or• to correct or ameliorate any physical or behavioral conditions.The submitted documentation does not support that the requested services are medically necessary for any of the following reasons: to prevent disease, disability, and other health conditions or their progression; to prolong life;…

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for a wearable cardiac defibrillator for treatment of the enrollee, who has a history of congestive heart failure.Findings: The physician reviewer found that The physician reviewer found in this circumstance, there is potential for recovery of left ventricular function over time with medical therapy. There was no documented indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time greater than 90 days where continued left ventricular dysfunction is documented to persist despite appropriate treatment.

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 congenital heart dft, then check the rights and deadlines that apply to your plan.