Stroke CVA: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for skilled nursing facility (SNF) services including physical therapy (PT) for 5 days/week x 1 hour/day until the enrollee is able to self-transfer to a wheelchair and wheels himself around, is able to self-transfer to a shower chair (and back to another chair), be able to walk on his own and be able to transfer assistance to home care; speech therapy (ST) for 5 days/week x 1 hour/day, until the enrollee is able to eat and swallow without aspiration risk (to get rid of the PEG-tube), be able to transfer assistance to home care, and speak enough to communicate and occupational therapy (OT) for 5 days/week x 30 minutes/day, until the enrollee is able to feed himself, to have control of his hands, be able to dress himself, brush his teeth and possibly be a…

Physician 1: The patient is a two-year-old female with neonatal right-sided hemiparesis. Some degree of improvement has already been achieved with the use of neuromuscular electrical stimulation therapy (e.g., increased mobility). The patient’s parent has requested authorization and coverage for a neuromuscular electrical stimulation device. The Health Plan has denied this request indicating the requested equipment is considered experimental.Neuromuscular electrical stimulation devices have been shown to be very useful for treatment of patients such as this patient. The device will prevent severe contractures in a developing child such as this patient, and therefore, is medically indicated. The rehabilitation literature is replete with positive results, and the device has proven clinical value.

Where the denial was upheld

Physician 1: The patient is a 52-year-old man who had a cardiac transplant in February 2004. He requires chronic immunosuppressive therapy to prevent rejection. A consultative report in February 2005, indicates the patient was enrolled in the IMAGE protocol comparing the efficacy and safety of molecular gene profiling (AlloMap testing) for the detection of acute rejection in heart transplant patients, compared with the conventional method of endomyocardial biopsy. The Health Plan has denied coverage for AlloMap testing on the basis it is considered experimental.AlloMap testing is a procedure in an early investigational phase. To date, there is no published literature demonstrating the efficacy of AlloMap testing for patients such as this patient. Thus, the testing at issue has not been established to be more effective than any available standard diagnostic modalities.

Nature of Statutory Criteria/Case Summary: The patient sustained a stroke, which affected his motor and sensory systems on the left side. He has been treated with outpatient therapy since August 2016, which has included therapeutic exercise, therapeutic activities, and neuromuscular re-education. From August 2016 to December 2016, the patient attended therapy that was aimed at decreasing his impairments, improving left-sided motor control, and improving his overall functioning. The patient was noted to be less fearful using his left lower limb for tasks such as standing in the kitchen and dressing himself. Decreased left shoulder tightness and inconsistent improvements in active assisted shoulder flexion were noted. There had been no improvements in active movements of his left hand. His left hand was tight, and he was not consistently wearing his left wrist-hand orthosis.

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 stroke cva was denied, the published record says the denial is worth fighting.