Skin Lesion 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 Afirma gene expression classifier test. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee’s indeterminate thyroid nodule. Findings: The physician reviewer found that The patient is diagnosed with a 3.5 cm nodule in left thyroid lobe. Thyroid biopsy cytopathology was consistent with atypia of undetermined significance (AUS). The specimen was then sent for molecular testing resulting in suspicious results. The patient has requested reimbursement for the Afirma gene expression classifier. The Health Plan denied reimbursement and noted that the gene testing was investigational for the evaluation of this patient.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing for evaluation of the enrollee’s thyroid nodules. Findings: The physician reviewer found that The physician reviewer found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Juvederm injections for treatment of her medical condition. Findings: The physician reviewer found that in this patient’s case, the condition constitutes an abnormal structure of the body. The patient has evidence of lesions/changes that are consistent with chronic biting. The patient also has some evidence of facial soft tissue atrophy. This would be considered abnormal. The chronic biting provides a form of trauma that has led to the lesions/condition. However, the requested services will not be performed to improve function. The use of Juvederm as a functional treatment of her chronic biting is not a standard therapy. In addition, conservative management and other treatment choices have not been adequately documented.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 120 units of hyperbaric oxygen therapy (HBOT), press full body chamber. The records provided for review document that this transgender patient underwent a body contouring procedure with grafting of 1100 cc of fat to the flanks and buttocks. Postoperative evaluation two days after the procedure showed normal postoperative healing with swelling, tenderness, and ecchymosis. There was no report of findings indicating compromised healing of the liposuction or the fat grafted areas or threatened or compromised surgical grafts. The patient’s provider has recommended treatment with HBOT.

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