Short Of Breath: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for immunoglobulin G (IgG) testing (CPT 86001 x 6) for evaluation of the enrollee, who reported a history of chest tightness and pressure. Findings: The physician reviewer found that allergic bronchopulmonary aspergillosis (ABPA) is an immunologic bronchopulmonary inflammation due to an immune response against Aspergillus fumigatus. The major clinical features of ABPA include asthma, recurrent pulmonary infiltrates, immediate wheal-and-flare skin reactivity to Aspergillus fumigatus, elevated total serum immunoglobulin E (IgE) levels, detectable serum precipitating antibodies to Aspergillus fumigatus, peripheral blood eosinophilia, elevated levels of Aspergillus-specific serum IgE and central bronchiectasis.

The patient is a 49-year-old male who is HIV positive and under the care of a HIV care physician who has requested a recombinant human growth hormone (Serostim) to treat severe lipohypertrophy (also referred to as visceral adipose tissue accumulation or lipodystrophy).He is described as having massive accumulation of intra-abdominal fat, which interferes with his activities of daily living and has caused shortness of breath and exacerbated his asthma by compressing the diaphram and causing obstructive lung disease. In addition, both a neurologist and a neurosurgeon have diagnosed neuralgia parasitica causing numbness of the thighs, legs and feet. The cause of this is nerve compression caused by progressive increase in abdominal girth due to the visceral fat accumulation of HIV lipodystrophy.

Where the denial was upheld

Physician 1: The patient is a 60-year-old female who was recently involved in a motor vehicle accident. An emergency CT scan was performed to rule out fracture or intra-abdominal injury. The chest CT revealed 3mm calcified nodule in the right mid lung. Enlarged lymph nodes were identified in the hilar and pre-carinal regions measuring up to 4.2cm in the left hilum. Right hilar and sub-carinal calcifications were also present. The abdominal and pelvic CTs were negative. The findings are consistent with previous granulomatous disease and bilateral hilar and mediastinal adenopathy of unknown etiology. The patient also has a history of recent weight loss and chronic GI symptoms. The patient’s clinician has requested authorization for a PET scan to further evaluate the adenopathy.

A 41-year-old female enrollee has requested CPT codes, 99215, 36415, 76977, 82270 X 3, 82365, 82397 x 122, 99000, 99001, 93720, 93922 x 2, 94010 x 2, A4649 x 4, A4556NU, A4617NU X 2, A4927NU, 99214, and 82365, for evaluation of her medical condition. Findings: The physician reviewer found that with regard to CPT code 76977 (bone mass screening by ultrasound), this study was not medically necessary in a patient of this patient’s age without a history of hyperparathyroidism. In addition, there were no clinical indications for CPT code 82365 (infrared spectroscopy) based on the documentation provided. CPT code 82397 (chemoluminescence), is not within the standard of care in this particular setting and thus was not medically necessary. CPT code 93720 (body plethysmography) is indicated for patients who have air spaces within the lung that do not communicate with the bronchial tree.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for short of breath was denied, the published record says the denial is worth fighting.