Postural Orthostatic Tachycardia Syndrome denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee requested coverage for Autonomic Nervous Function Test. The enrollee underwent autonomic nervous function testing after experiencing ongoing symptoms of dizziness, chest pain, dyspnea, tachycardia, near syncope and burning/tingling sensations. The documentation indicated she initially underwent a cardiac consultation complaining of three episodes of pre-syncope. The documentation detailed the enrollee has seen a pulmonologist and pulmonary function testing did not identify a reason for this. She has also seen gastroenterology and endocrinology. The physical examination did not reveal any significant abnormalities. The patient's laboratory studies were normal. An ECG showed normal sinus rhythm.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a tilt table test. The records document that this patient presented to her provider with complaints of dizziness and palpitations. The patient is noted to have a history of Ehlers-Danlos syndrome and mast cell activation syndrome. Palpitations are sensations of a rapid or irregular heartbeat and are commonly caused by cardiac arrhythmias or anxiety, though there are many other causes as well. When palpitations are accompanied by dizziness, it is considered a more serious condition that requires further assessment. The patient underwent evaluation for unexplained symptoms of dizziness and palpitations with an echocardiogram, which was normal, and Zio monitor, which demonstrated abnormal atrial tachycardia.

Where the denial was upheld

The parent of a 16-year-old female enrollee requested: (1) neuro-ophthalmology referral; (2) panel for paraneoplastic antibodies including but not limited to anti-gangliocyte panel; (3) magnetic resonance imaging (MRI) of the abdomen with and without contrast; (4) MRI of the cervical spine with and without contrast; (5) MRI of the chest with and without contrast; (6) MRI of the lumbar spine with and without contrast; (7) MRI of the thoracic spine with and without contrast; (8) XR modified barium swallow with an occupational therapist (OT) or speech language pathologist (SLP); (9) motion fluoroscopic evaluation; swallow function; cine/video recording; and (10) swallowing function with cineradiography or videography, for medical evaluation and/or treatment of the enrollee’s dysautonomia, postural orthostatic tachycardia syndrome (POTS) and autonomic neuropathy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for IVIG therapy.The submitted clinical documentation does not support that IVIG therapy is medically necessary for the patient. There are no visit notes demonstrating how diagnoses of mast cell activation syndrome (MCAS), Ehlers-Danlos syndrome or postural hypotension syndrome (POTS) were made. All of the patient’s submitted mast cell studies were normal and the records fail to demonstrate evidence of mast cell activation syndrome.

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 postural orthostatic tachycardia syndrome, then check the rights and deadlines that apply to your plan.