Dementia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fluorodeoxyglucose-positron emission tomography (FDG-PET) scan for evaluation of the enrollee’s memory loss. Findings: The three physician reviewers found that there is a growing body of literature supporting the use of fluorodeoxyglucose (FDG-PET) in this clinical setting. Neuroimaging has come to play an important role in the diagnosis and characterization of dementia. This technique can help guide treatment and aid avoid ineffective therapy. Neuroimaging can be divided into structural imaging (computed tomography, MRI) and functional imaging (FDG-PET imaging, functional MRI). FDG-PET is a biomarker for neuronal degeneration in dementia and when used appropriately, can add valuable information to the patient’s clinical workup.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genetic testing. Neurodegenerative disease accounts for the majority of dementia diagnoses. These range from common dementia diagnoses such as Alzheimer's disease to frontotemporal dementia (FTD) and prion diseases. Genetic testing has helped identify several etiologies of dementia. The standard available testing is genetic panel testing. Whole exome genetic testing reduces bias and provides greater diagnostic yield as compared to genetic panel testing. Furthermore, whole exome testing can detect several genetic pathologies including duplications, deletions, insertions, and inversions beyond the scope of panel testing. Finally, whole exome testing enables further data analysis should new clinical information become available.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) skilled services by a registered nurse for management and evaluation of the plan of care (CPT code G0162), 1 unit at 15 minutes each, and (2) direct skilled nursing services of a registered nurse in the home health or hospice setting (CPT code G0299), 3 units at each 15 minutes. Green notes that patients with dementia have unique safety needs due to cognitive and behavioral changes associated with dementia. The author further notes that safety interventions for persons with dementia who remain in their home environment should be considered to mitigate the risks associated with falling, kitchen use and food safety, medication safety, and wandering and personal safety. Despite these measures, constant supervision and caregiver assistance for safety may still be needed.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) services for rehabilitation services including physical therapy, occupational therapy, and speech therapy. Dementia is progressive and results in various adverse outcomes such as impaired social participation, compromised self-care abilities, and increased hospitalizations. Management options include redirection, structured care and support, involvement in stimulating activities, cholinesterase inhibitors, and reducing unnecessary polypharmacy. In this case, the patient has a history of multiple, chronic brain insults with dementia, manifested by severe cognitive deficits affecting domains such as memory, sensorium, and safety awareness. She also has severe physical impairments.

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