Dizziness denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a computerized dynamic posturography sensory organization test. Computerized dynamic posturography provides a multisensory assessment of balance and measures the ability to incorporate vestibular, visual, and proprioceptive inputs to assess the functional status or vestibular compensation and inform vestibular rehabilitation. Based on the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines, computerized dynamic posturography is medically indicated and appropriate in the evaluation or therapy of certain individuals with suspected balance or dizziness.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a tilt table test. The records document that this patient presented to her provider with complaints of dizziness and palpitations. The patient is noted to have a history of Ehlers-Danlos syndrome and mast cell activation syndrome. Palpitations are sensations of a rapid or irregular heartbeat and are commonly caused by cardiac arrhythmias or anxiety, though there are many other causes as well. When palpitations are accompanied by dizziness, it is considered a more serious condition that requires further assessment. The patient underwent evaluation for unexplained symptoms of dizziness and palpitations with an echocardiogram, which was normal, and Zio monitor, which demonstrated abnormal atrial tachycardia.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a computed tomography (CT) scan or magnetic resonance spectroscopy (MRS) or angiography and magnetic resonance angiography (MRA) scan. The Health Plan has denied this request indicating that the requested diagnostic procedures are not medically necessary for evaluation of the enrollee’s dizziness. The requested for CT scan, MRS or angiography and MRA scan are not medically necessary for evaluation of the patient’s medical condition. In this case, the patient has a history of dizziness without evidence of other neurologic deficits. Symptoms have been present for at least four years, and the patient has been seen by a neurologist, who did not detect an underlying disease. In addition, the patient underwent an MRI of the brain in 2016 which was negative.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for 30-day CardioNet mobile cardiac outpatient telemetry (CPT 93229). The patient has a low risk of a life-threatening arrhythmia based on his age, personal history, and family history. The records report that the patient’s echocardiogram was normal and he has no history of syncope. Current guidelines generally recommend external patient triggered or automated loop recorders for patients with infrequent symptoms. Use of MCOT real time monitoring is reserved for symptomatic patients with a high likelihood of life-threatening arrhythmias requiring immediate action or attention. This patient has infrequent but longstanding dizziness episodes without syncope. The records do not include any prior investigations for arrhythmia or evidence of structural heart disease.

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