Lymph Nodes denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 42-year-old male who had a right orchiectomy in August 2004 for seminoma. A 1.4cm retroperitoneal lymph node was identified on a follow-up CT scan. MRI of the abdomen in March 2006 showed increased activity in the retroperitoneal lymph node and in the right axilla. The patient received radiation therapy to his periaortic and pelvic lymph nodes. No abnormality was identified in the right axilla on the CT scan. A follow-up PET scan has been ordered to assess the activity in the axilla. The Health Plan has denied coverage for the requested PET scan.Prior Centers for Medicare and Medicaid Services (CMS) reimbursement standards did not include testicular cancer as an indication for PET scan.

Physician 1: The patient is a 42-year-old male who was diagnosed with T2 N0 M0 seminoma of the testicle on August 2004. He was treated with surgery alone, followed by surveillance for recurrence. In October 2005 a CAT scan identified a new 1.4 cm lymph node in the retroperitoneum. A follow-up MRI in March 2006 showed a slight enlargement of the node to 1.6 cm and a new 1.8 cm lesion in the L2 vertebral body. Neither of the lesions is definitively representative of recurrent cancer. The patient’s provider requested authorization for a PET scan to further analyze the clinical situation. The Health Plan denied authorization citing the investigational nature of the procedure in this clinical context.PET scans are a very different kind of scan than MRI or CAT scan.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for an increase of hydrocodone and morphine. Findings: The physician reviewer found that dose escalation is not a long term plan but a short term plan for the treatment of tolerance. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in the documentation available for review, no objective treatment goals for pain and function were noted for the requested medication dosage increase. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for air ambulance service provided on 12/27/17. The Health Plan has denied this request indicating that the requested service was not medically necessary for treatment of the enrollees epilepsy.At issue in this case is whether the requested air ambulance service was medically necessary for treatment of the enrollees medical condition.In most cases, air ambulance transport is reserved for use in emergent situations in which ground transport is not feasible or readily available. Such situations from the neurology perspective include (but are not limited to), intracranial hemorrhages, strokes requiring endovascular therapy or other conditions requiring acute surgical intervention.

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