Dizziness Vertigo denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A 67-year-old female enrollee has requested authorization and coverage for functional endoscopic sinus surgery and septoplasty.. The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollee’s deviated nasal septum; nasal turbinate hypertrophy; chronic sinus infection; chronic sinusitis; and nasal polyps.At issue in this case is whether the requested functional endoscopic sinus surgery and septoplasty are medically necessary for treatment of the patient’s medical condition.Per researchers, nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but their etiology is unknown.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for vestibular rehabilitation services. Researchers report that in persistent postural-perceptual dizziness (PPPD) and related disorders, vestibular rehabilitation combined with cognitive-behavioral therapy (CBT), and possibly supported by medication, may help patients escape a cycle of maladaptive balance control, recalibrate vestibular systems, and regain independence in daily life. The authors note that PPPD may be managed with effective communication and tailored treatment strategies including specialized physical therapy such as vestibular rehabilitation, serotonergic medications, and CBT.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for alternative surgical positioning, without laying the patient flat and without inverting the patient, during total hysterectomy with bilateral salpingo-oophorectomy surgery. Laparotomy, laparoscopic, and robotic hysterectomy are all surgical approaches for the removal of the uterus. Several factors should be considered in determining which approach to select, including the indication for the hysterectomy, the size and position of the uterus, the presence of other pelvic pathologies, patient factors, and surgeon expertise. Laparotomy involves a larger abdominal incision and is generally reserved for situations when laparoscopy is not feasible. Laparoscopic hysterectomy is minimally invasive and is associated with a shorter hospital stay, less postoperative pain, and faster recovery.

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.

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