Infection: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sirturo (bedaquiline fumarate 100 mg tablet), dosed at 400 mg daily for 14 days, then 200 mg daily for three months total therapy. Findings: The physician reviewer found that the available medical records, the provider has followed an appropriate plan of treatment with use of progressively more aggressive therapeutics for management of this patient’s Mycobacterium abscessus (M. abscessus). The provider initially used standard oral medications and transitioned when near pan-resistance was noted. He then escalated to prolonged courses of intravenous (IV) amikacin, and tigecycline, in addition to IV imipenem. Despite these measures, the patient has failed to completely respond, and she required a return to surgery earlier in 2020 to resect out the affected area.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with morphea of the right breast. The patient initially developed a lesion on the right breast. A biopsy performed revealed an inflamed sinus tract. The physical examination findings included a large geometric plaque with scarring and lichenification on the right breast. No areas of erythema, drainage, nodules, or open ulcers were noted. The provider noted that there were no signs of infection or inflammation.The patient has requested authorization and coverage for tacrolimus 0.1% ointment. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether tacrolimus 0.1% ointment is medically necessary for treatment of the patient’s medical condition.

Where the denial was upheld

The patient is a 77-year-old female with an extensive history of excessive tearing. By her own report, this condition has worsened over the years and problems with eye infections and visual impairment have occurred. An ophthalmologist saw her in March 2003 for these problems and referred her to a plastic surgeon for correction of “epiphora secondary to inferior lid lag.” There is a visual field chart included with this patient’s records, but the ophthalmologist made no interpretation and there is no mention of visual field defect in his referral letter. The patient subsequently underwent extensive facial surgery. Pre-operative photos support the presence of lower lid lag with ectropion and upper lid and brow ptosis.

An enrollee has requested authorization and coverage for in-patient acute level of care services.Irmak and colleagues state that, although reconstruction is still a controversial issue in elderly patients with advanced pressure ulcers, it has been established that infection, protein loss, morbidity, and mortality will increase in patients without proper debridement and reconstruction. Appropriate patient selection, debridement, and reconstruction with appropriate postoperative rehabilitation can be very beneficial in elderly patients. In patients whose general health condition is a contraindication for surgery, at a minimum, progression of pressure ulcers can be prevented with good wound care and conservative treatment.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for infection was denied, the published record says the denial is worth fighting.