Deformities denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for surgical procedures performed to either or both thighs. One study states that, “The use of autologous grafted subcutaneous adipose tissue is increasing in popularity worldwide for soft tissue augmentation, especially on the face, breast, and buttocks. This is known as autologous fat transfer (AFT). Advantages of this technique include complete biocompatibility, natural feel of tissue, easy availability of donor tissue in most patients… and potentially permanent results.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with a left ring finger proximal interphalangeal (PIP) joint flexion contracture. Physical examination findings included mild swelling of the left ring finger. Left ring finger PIP joint range of motion was to 45 degrees in extension. The collateral ligaments were stable to stress testing, and the patient denied experiencing pain on stress testing. There was reasonable strength and intact sensation. In a letter, the provider noted the patient sustained trauma to his left ring finger. The patient has been treated with hand therapy with dynamic splinting and range of motion exercises. The provider noted that the patient developed a flexion contracture of the PIP joint, which was static.

Where the denial was upheld

Physician 1: The patient is a 62-year-old male who primarily has a metatarsophalangeal joint (MPJ) Dupuytren’s contracture. He has requested authorization and coverage for a needle aponeurotomy. The Health Plan has denied this request indicating that the efficacy of needle aponeurotomy has not yet been established.Needle aponeurotomy is a commonly used technique in France for the management of Dupuytren’s contracture. Currently, there are very few surgeons in the United States who use this approach to treat Dupuytren’s disease. The technique involves inserting needles underneath the skin to divide the cord that is contracting the digit. Because the procedure does not involve a skin incision, it is less morbid than a standard Dupuytren’s release.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine sulfate ER 45 mg two times daily. The Health Plan has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollee’s chronic pain syndrome. Findings: The submitted documentation fails to demonstrate the medical necessity of the requested medication quantity in this clinical setting. The step wise World Health Organization ladder for pain relief is considered a reasonable approach for pain control in the palliative and the non-palliative setting. However, in the documentation available for review, there are no objective treatment goals for pain and function noted for the requested medication.

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