Nausea 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 individual acupuncture for treatment of headaches, musculoskeletal pain and nausea. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. The records note a recent flare-up of her chronic neck, shoulder and lower back condition related to a fall. Due to the severity of the pain, medication was required which produced nausea and lightheadedness. Researchers described the effectiveness of complementary and alternative medicine therapies compared to placebo, no intervention, or other interventions for acute/subacute and chronic low back pain. The authors noted that acupuncture is more effective than no treatment for chronic low back pain.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acupuncture treatments for treatment of the enrollee’s fatigue, insomnia, nausea and vertigo. Findings: The physician reviewer found that acupuncture has been shown to be effective for the management of pain and fatigue related to illness. Acupuncture has demonstrated benefit across a variety of conditions including chronic pain. Peer-reviewed publications provide support for acupuncture in treating anxiety, sleep disturbances, depression and chronic pain. Acupuncture relieves pain better than sham acupuncture, as measured at completion of treatment and at short-term follow-up. The medical records document that this patient has been treated with acupuncture with reported good response and functional gain.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Zofran. The submitted documentation fails to demonstrate the medical necessity of the requested medication regimen. There is a lack of documentation indicating the patient was treated by a physical health provider. This patient has chronic nausea associated with her medical condition. Although the patient has a diagnosis of irritable bowel syndrome and gallstones, there is a lack of documentation to support that these conditions are the cause of the patient’s chronic nausea. The treatment for a patient with chronic and prolonged symptoms associated with her medical condition includes medication and cognitive behavioral therapy. Medication choice typically includes a serotonergic reuptake inhibitor antidepressant.

A 79-year-old male enrollee has requested emergency transport for treatment of his medical condition. Findings: The physician reviewer found that at issue in this case is whether a prudent layperson in the patient’s circumstances would have believed that emergency transport to the hospital was medically necessary. California law defines an “emergency medical condition” as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patient’s health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.The submitted documentation states that the patient was worried about pain in his chest.

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