Deep Vein Thrombosis: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Factor V Leiden genetic testing. Thrombophilias are hereditary or acquired conditions which can increase the risk of venous or arterial thrombosis (Stevens, et al.). As the etiology of thrombosis is multifactorial, the presence of a thrombophilic defect is only one of many elements that determine a patient’s risk. Factors associated with an inherited thrombophilia include venous thrombotic event at a young age, a strong family history, venous thrombotic event in conjunction with weak provoking factors at a young age, recurrent venous thrombotic event, and venous thrombotic event in an unusual site.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test (prothrombin G20210A (Factor II) mutation testing) for evaluation of the enrollee’s deep vein thrombosis. Findings: The 3 physician reviewers found that Data from observational studies report that the highest rates of inheritable thrombotic disorders are in patients with a family history. Testing for the presence of inherited thrombophilias is recommended. Prothrombin G20210A mutation may be suspected in an individual with familial thrombophilia, a known familial prothrombin G20210A mutation, venous thromboembolism (VTE) at an early age or unusual site, or recurrent VTE. As this patient has an extensive VTE and a mother with recurrent VTE. Thus, testing was clinically indicated to for evaluation and treatment.

Where the denial was upheld

Physician 1: The patient is a 62-year-old male with post-phlebitic syndrome and a history of deep vein thromboses (DVT). He has associated lymphedema and varicose veins secondary to his DVT. The patient has bilateral deep venous incompetence with residual thrombus in his right leg. His provider has requested authorization for endovenous laser ablation and six sessions of ultrasound guided sclerotherapy for both legs. The Health Plan denied the request citing the experimental/investigational nature of the therapy.The patient has symptomatic post-thrombotic syndrome. Interventions on the right greater saphenous vein and multiple varicosities could potentially worsen his condition. Intervention on his left leg may assist his condition. The patient is at high risk for recurrent DVT on the right, irrespective of the modality used.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for iliac vein stenting of the right lower extremity. The records provided for review document that this patient has a history of recurrent right lower extremity deep vein thrombosis (DVT). The provider has recommended enrolling the patient in a chronic venous thrombosis relief with adjunctive catheter directed therapy (C-TRACT) randomized controlled trial.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for deep vein thrombosis was denied, the published record says the denial is worth fighting.