Cystic Fibrosis denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 22-year-old male diagnosed with cystic fibrosis in January 1985. Since then, he has had multiple hospitalizations and has been treated for ABPA, pulmonary hemorrhage, pancreatic insufficiency and bronchiectasis. The submitted notes indicate the patient’s FEV1 was 50% in August 2003. The patient was hospitalized in September 2003 because of decreasing pulmonary functions. After hospitalization, his FEV1 improved to 66%. During hospitalization, the patient was given treatments with an IPV device, which appeared to improve the amount of expectorated sputum.Upon discharge, subsequent pulmonary function tests showed incremental decrease in the patient’s lung functions. Recently, the patient’s FEV1 was 58%. According to the patient’s provider, the patient lives alone and works full-time.

The patient is a 21-year-old female with cystic fibrosis. The patient’s provider indicates the patient has benefited from use of the Vest Airway Clearance System (the Vest system) and has had only two hospitalizations while using the device. The patient’s provider also notes the patient has used both a Flutter device and chest physiotherapy (CPT) with minimal success. A hospital discharge summary from June 2004 states the patient was admitted for 48 hours of hemoptysis. The patient was discharged on intravenous antibiotics for cystic fibrosis exacerbation. The record also shows the patient had a baby in March 2004 and that she is the primary caregiver for her child. A request has been made for continued use of the Vest system.

Where the denial was upheld

A 49-year-old female has requested coverage for past emergency surgical services on four separate dates. Findings: The physician reviewer found that the patient has a history of cystic fibrosis and invasive fungal infection of the lung resulting in hemoptysis. She underwent surgery to remove the infected tissue; however, several months later she re-presented with recurrent symptoms and required full pneumonectomy to remove the entire lung on the right side. This left a “dead space,” and she again presented with cough and brownish sputum. Workup showed erosion of the bronchial stump with empyema and chronic infection with aspiration of fungal material into the opposite lung. Attempts to use biologic glue failed. The patient had right video thoracoscopy in to evacuate the infected space and place a tracheal stent to cover the opening.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with pancreatic insufficiency, cystic fibrosis (CF) and severe obstructive airway disease. The patient is managed with maximal medical therapy, which includes Pulmozyme, hypertonic nebulized saline, azithromycin, and an airway clearance device. She is currently using a Hill-ROM vest, which provides high-frequency chest wall oscillation. The patient’s pulmonary tests have been stable per the records provided. The patient has requested authorization and coverage for a high frequency chest compression device (Monarch Vest System). The Health Plan has denied this request, indicating that the requested device is not medically necessary for the treatment of this patient. The patient has requested an upgraded device for airway clearance.

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