Osteopenia denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bone density study. According researchers guidelines, bone density screening is recommended for postmenopausal women under age 65 with one risk factor. The detection of subclinical vertebral fractures using dual-energy x-ray absorptiometry (DEXA) vertebral fracture assessment is well established across current medical literature as results may alter clinical management. Recommendations for postmenopausal women over age 50 may include fracture, height loss, or glucocorticoid treatment. Other criteria include osteopenia and two or more of the following: being aged 60 to 69 years old, self-reported nonvertebral fractures, height loss, and chronic diseases associated with an increased risk of vertebral fractures.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Ensure formula.Poor nutrition is common in individuals with cerebral palsy and has a wide-ranging impact on their health and well-being (Rempel, G.). Ruiz Brunner and colleagues conducted a cross-sectional study to describe the nutritional status of children with cerebral palsy (CP) and to analyze their risk of undernutrition based on their Gross Motor Function Classification System (GMFCS) level. They found that there is a high prevalence of undernutrition associated with CP (GMFCS levels IV and V) and that risk of severe undernutrition increases with increased motor compromises. Bell and Samson-Fang note that children with severe cerebral palsy, and particularly those with oropharyngeal dysfunction, are at high risk of poor nutritional status.

Where the denial was upheld

The patient is a 58-year-old woman who has requested authorization and coverage for a bone density evaluation. There is no prior history of fracture or family history of hip fracture. There is no prior history of excess thyroid, long-term steroid use, smoking or any other factor that might suggest an increased risk for a premature fragility fracture. The submitted records indicate the patient stopped taking Premarin as of June 2004. The Health Plan has denied coverage for the requested bone density scan on the basis that it is not medically necessary for evaluation of the patient’s condition.There is some consensus about which post-menopausal women younger than age 65 should be screened for osteoporosis with a DEXA scan.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for an Osteoboost osteogenesis stimulator. U.S. Food and Drug Administration (FDA)-approved treatments for post-menopausal bone loss aim to slow resorption or promote formation. Bisphosphonates and selective estrogen receptor modulators are the most common antiresorptive options. Estrogen therapy can also prevent bone loss in early osteopenia. Denosumab, a monoclonal antibody that inhibits osteoclast activity, provides another effective antiresorptive approach, while anabolic agents such as teriparatide and abaloparatide stimulate bone formation in severe cases. Osteoboost precision mechanical stimulation device is an FDA-approved wearable medical device. Osteoboost has been found to be effective for treating osteopenia.

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