Headache 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 magnetic resonance imaging (MRI) of the brain stem with and without contrast material.For evaluation of headaches, most patients can be diagnosed without testing. However, some serious disorders may require urgent or immediate testing. Computed tomography (CT) or MRI should be done as soon as possible in patients with any of the following findings: thunderclap headache, altered mental status, meningismus, papilledema, signs of sepsis, acute focal neurologic deficit, or severe hypertension. (Silberstein, S.).

A 66-year-old male enrollee has requested a CT thorax, CT abdomen, MRI brain and MRI thoracic spine for an evaluation of his upper epigastric discomfort, back pain an headaches. Findings: The physician reviewer found that this patient presented with pleuritic type chest pain and difficulty breathing. The chest x-ray showed no acute disease, and the patient’s symptoms persisted following a trial of antibiotics. These symptoms could be due to infectious or inflammatory disease of the chest, pulmonary embolism or pericarditis. CT scan of the thorax can evaluate for pulmonary embolism/infarct, small areas of infection not visible on chest x-ray and areas of inflammation within the lung and/or pericardium. With a normal chest x-ray and continued symptoms following antibiotic therapy, a CT of the thorax was medically appropriate.

Where the denial was upheld

Physician 1: The patient is a 34-year-old female with chronic headache and neck pain for two years after a motor vehicle accident. She has been followed by a pain management specialist who has treated her with narcotics, muscle relaxants, trigger point injections, occipital nerve blocks and botulinum toxin type B (Myobloc) injections. The patient has continued to experience moderate to severe pain. The Myobloc injections on several occasions resulted in modest and short-lasting pain relief. The patient wishes to receive additional Myobloc injections. The Health Plan has denied coverage for Myobloc on the basis it is considered investigational for treatment of migraine headaches.There are very limited studies involving Myobloc in the treatment of headache or neck pain with no placebo-controlled studies.

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency services on an emergent basis or urgent basis. Findings: The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a headache. She also had been experiencing sinus congestion, rhinorrhea, sore throat and earache. She did not report any symptoms of confusion, or disorientation. The patient was mildly tachycardic, but was afebrile. She was described as in no acute distress. Based on the patient’s presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition.

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