Pulmonary Nodule denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electromagnetic navigational bronchoscopy (ENB)for treatment of the enrollee with history of pulmonary nodules. Findings: The physician reviewer found that transthoracic needle biopsy (TTNB) has a better diagnostic rate, there is a higher risk for pneumothorax, greater than 10% when compared to 3% to ENB. The primary disadvantage of TTNB is that a pneumothorax develops in 11% to 24% of patients and 5% to 14% require insertion of a chest tube. The National Comprehensive Cancer Network (NCCN) clinical practice guidelines for non small-cell lung cancer state that the strategy for diagnosing lung cancer should be individualized and the least invasive biopsy with the highest diagnostic yield is preferred as the initial diagnostic study.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a computed tomography (CT) scan of the chest. The records indicate that the patient has multiple unclear pulmonary nodules found incidentally on a CT scan of the cervical spine, of unclear etiology. Given the findings of the patient’s cervical spine CT scan, dedicated imaging of the patient’s chest is indicated and the next best step for workup of the unclear nodules. Identification of the size, characteristics, and possible additional lesions is required prior to the determination of interventions or diagnostic evaluation. As such, a dedicated CT scan of the chest is paramount to determine the course of action required for diagnosis and potential management of the patient’s condition. Without further imaging, the patient is at risk of receiving inadequate care.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the positron emission tomography/computed tomography (PET/CT) scan. Findings: Three physician reviewers found that in this patient’s case, the guidelines do not support the efficacy of the PET/CT scan at issue. This patient presented with an incidental finding of a 4 mm pulmonary nodule, noted on a CT scan. The Society of Thoracic Imaging and Diagnosis, otherwise known as the Fleischner Society, is a well-known organization that has established guidelines for the evaluation of incidentally detected pulmonary nodules. These evidence based guidelines were revised in 2017 and are widely used throughout radiology. For incidentally detected nodules that are greater than 8 mm, the Fleischner Society guidelines call for either a follow up CT scan in three months, and/or a PET/CT, and/or a biopsy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a positron emission tomography (PET) scan for evaluation of the enrollee’s lung nodule. Findings: Two of the three physician reviewers found that this patient presented with an incidental finding of a pulmonary nodule. He was then evaluated appropriately, first with a routine CT scan to confirm the presence of the nodule. At that point, a decision was needed concerning how to further evaluate the nodule. The Society of Thoracic Imaging and Diagnosis, otherwise known as the Fleischner Society, is a well-known organization that has established guidelines for the evaluation of incidentally detected pulmonary nodules.

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