Pregnancy 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 cell-free fetal DNA-based prenatal testing for fetal sex chromosome aneuploidies and microdeletion syndromes for evaluation of the enrollee’s pregnancy. Findings: The physician reviewers found that Fetal aneuploidy screening is supported for all pregnant patients by the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine. Cell-free DNA testing has been validated as having a high detection rate for fetal chromosomal abnormalities, including sex chromosomes. This patient’s age places her at increased risk for all fetal chromosomal abnormalities. Currently, the screening test of choice is cell-free DNA testing. Part of the commercial testing includes an analysis of fetal sex chromosomes. Fetal sex chromosomal abnormalities are common.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for fetal echocardiography with doppler color flow velocity mapping services. Findings: The physician reviewer found that guidelines and medical literature supports evaluation with an anatomic scan including standard cardiac anatomy in the latter part of the first trimester for all pregnancies. Data suggest that a subsequent separate fetal echocardiography is recommended when there is an increased risk of cardiac anomalies. As noted by Copel and colleagues, “The optimum gestational age for screening for structural fetal cardiac anomalies is 18 to 22 weeks of gestation.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for water birth, delayed cord clamping longer than two minutes, and in-home postnatal care and checkup.Water birth has been advocated as a non-pharmacologic technique. However, according to a review by Cluett and colleagues, evidence of the efficacy of water birth is limited since few randomized trials have been performed and most had a small number of subjects, wide variations in patient populations or study design, and methodological flaws.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test (fetal chromosomal aneuploidy) for evaluation of the enrollee who was undergoing prenatal care. Findings: The physician reviewer found that There is a lack of support in the medical literature for the services at issue. The American College of Obstetrics and Gynecology (ACOG) in conjunction with the Society for Maternal-Fetal Medicine recently (July 2015) addressed the issue of the use of cell free DNA testing, “given the performance of conventional screening methods, the limitations of cell free DNA screening performance, and the limited data on cost effectiveness in the low risk obstetrical population, conventional screening methods remain the most appropriate choice for first line screening for most women in the general obstetric population.” The chart does indicate that the patient had fi…

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