Peripheral Neuropathy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) of the pelvis and MRI/MRA of the lower extremity. The Health Plan has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollee who has a history of neuromuscular hamartoma (choristoma).Findings: In this patient’s case, the services at issue were medically necessary. While the ultimate diagnosis was a rare hamartoma, the referring provider had no way of predicting this, and it was important to exclude a space-occupying lesion, especially given the patient’s history of a prior nerve tumor. This diagnosis is rare, and the referring provider had no reason to suspect this diagnosis at the time of his evaluation of the patient.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for nerve testing. The autonomic nervous system regulates certain body processes including a patient’s blood pressure and rate of breathing. Disorders of the autonomic nervous system can affect any body part or process and can reversible or progressive. Establishing a diagnosis is helpful in determining appropriate further care. Autonomic testing including tilt table testing are supported as standard of care examinations of the autonomic system in the peer-reviewed medical literature.

Where the denial was upheld

Physician 1: The patient is a 47-year-old male who reportedly has peripheral neuropathy in the feet, with described loss of sensation and burning sensation. A report from his neurologist does not detail any abnormalities of sensation, strength or reflexes. No information is evident regarding confirmation of neuropathy by electrodiagnostic examination, or regarding diagnostic evaluation for etiology. The patient has reportedly tried Cymbalta, though the dose is not specified. He did not have benefit from it, though no side effects were specified. He reportedly has been on Neurontin but the dose and degree or lack of benefit is not indicated. No other medications for treatment of neuropathy are mentioned in the records provided.The patient was prescribed Anodyne therapy; treatment notes indicate he had short-term improvement.

Physician 1: The patient is a 59-year-old male with chronic foot pain related to peripheral neuropathy. Medical management apparently failed, and the patient was referred to a physical therapist who utilized Anodyne therapy treatments. The patient reports significant improvement in his painful symptoms and has requested reimbursement for a home Anodyne therapy unit he purchased. The Health Plan denied his request citing the experimental nature of the device.The Anodyne therapy unit has been FDA approved since 1994. It is in use by over half of a million patients and many podiatrists have come to appreciate the benefits of this therapeutic device. The patient had previously tried many other treatments modalities, and none had provided measurable relief.

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