COPD denials in California external review

What the reviewers wrote

Where the denial was overturned

Physcian 1: The patient is a 55-year-old woman with hypogammaglobulinemia and bronchiectasis. She has been well treated by established methods with limited success. However, with The Vest therapy she has noted better and more efficient expectoration and improved quality of life. There is no spirometric evidence of improvement provided, but her steroid dose has been reduced. The Health Plan denied authorization and coverage for The Vest based upon their determination that it is investigational for the treatment of bronchiectasis.As the standard therapies have been tried with limited success and The Vest seems to be successful and practical, it is appropriate that the patient continue with this treatment. Spirometric evidence of improvement is not essential.

The patient is a 59-year-old male who has end-stage COPD requiring continuous supplemental oxygen. He is receiving long-term treatment with steroids and frequent treatment with oral antibiotics. The patient is also Hepatitis C positive. The record indicates the patient has been evaluated for a single lung transplant at two transplant centers and both determined he was not a candidate due to his Hepatitis C status. The patient then consulted with the Cleveland Clinic, which apparently has accepted him as a single lung transplant candidate. This is a patient with end stage lung disease who also has hepatitis C. At issue is whether the patient is a candidate for a lung transplant. Three reasons were stated as to why the patient may not be a candidate despite meeting all other criteria to be listed as a candidate. The prime reason is the presence of Hepatitis C in the patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Marinol for treatment of the enrollee’s chronic obstructive pulmonary disease. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. There is little to no literature on the role of marijuana or cannabinoids in the management of breathlessness as a complication of advanced lung disease, largely because research on this family of drugs is limited. To date, the evidence demonstrates some benefits for cannabinoids in symptom relief for chronic neuropathic pain, cancer pain and multiple sclerosis related spasticity, otherwise the data was graded as low or very low quality. Further, the reported adverse effects often were more debilitating than the disorder being treated.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services, including physical therapy, respiratory treatments, blood oxygen and CO2 monitoring. Admission to an SNF is appropriate for patients with conditions that require observation, evaluation of treatment plans, and updating of orders by a physician as well as constantly available skilled nursing services. Patients require skilled nursing services, including wound management, tracheostomy care, bowel and bladder training and tube feeding, and administration of intravenous (IV) medications or medications that cannot be self-administered safely.

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