Post-concussion Syndrome 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: The patient has requested reimbursement for Intensive NeuroRestoration Program services, including hyperbaric oxygen therapy, therapeutic exercises, therapeutic activities, and manual therapy. In this clinical scenario, the patient was diagnosed with traumatic brain injury (TBI) and post-concussion syndrome. On review of the records, the patient’s presentation is consistent with post-concussion syndrome based on the history and physical findings including the Rivermead Post-Concussion Symptoms Questionnaire results. TBI can cause symptoms including headache, blurred vision, dizziness, as well as changes in consciousness, and problems with memory.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computerized dynamic posturography, quantitative electroencephalogram, Cambridge Brain Sciences Cognitive Test, and/or videonystagmography. Based on the available documentation, this patient presented to his provider with complaints of vertigo, headache, difficulty falling asleep and tiredness after sustaining head trauma from a water bottle. The patient underwent evaluation with computed tomography (CT) of the head and magnetic resonance imaging (MRI) of the brain, which were interpreted as normal. The patient has symptoms suggestive of post-concussion syndrome. The use of the above the quantitative electroencephalogram and Cambridge Brain Sciences Cognitive Test would not alter the treatment of post-concussion syndrome.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for outpatient vestibular (physical therapy) twice a week for eight weeks (CPT 97163 – physical therapy evaluation high complex; 97162 – physical therapy evaluation mod complex; 97110 – therapeutic exercises (including ROM, flexibility, endurance); 97112 – neuromuscular re-education)); and outpatient speech therapy (cognitive speech therapy) twice a week for six weeks (92522 – evaluation speech; 96125 – cognitive performance test; 97129 – therapy interventions/focus on cognition 30 minutes; 97130 – therapy interventions/focus on cognition additional 15 minutes).

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. Findings: The physician reviewer found that in this case has experienced chronic, persistent symptoms following remote head traumas. She has undergone vestibular rehabilitation without objective clinical benefit in the past and more recently with some subjective benefit reported. Based on the records provided for review, the patient has undergone sufficient rehabilitation to be independent with a home exercise and self-management program to further improve her balance, endurance, and activity tolerance. The provider noted that the patient is able to exercise on her own without difficulty, and she is participating in a yoga program focused on a history of brain injury.

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 post-concussion syndrome, then check the rights and deadlines that apply to your plan.