Thyroid Nodule With Atypia Of Undetermined Significance: 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 Afirma gene expression classifier test performed.Findings: The physician reviewer found that the patient with a 1.3 cm right thyroid nodule. According to the medical notes, the patient had a prior biopsy which was consistent with undetermined significance. The patient underwent a follow up biopsy that also returned atypia of undetermined significance. The specimen was sent for Afirma gene expression classifier testing, which returned a benign result. The Health Plan has declined reimbursement for this test. A specimen was subsequently sent for Afirma gene expression classifier test performed. The Health Plan denied reimbursement noting the services at issue were investigational for evaluation of this patient’s medical condition.

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.

Where the denial was upheld

Findings: The physician reviewer found that a patient has requested authorization and coverage for the remote access approach for a thyroidectomy. While thyroidectomy is traditionally performed through a transcervical incision, remote access techniques have been developed primarily for cosmetic benefit. Expert guidance indicates that remote access thyroidectomy should be limited to Bethesda class III nodules measuring 4 cm or less. In this case, the patient has a 4.8 cm left thyroid nodule with atypia of undetermined significance, which exceeds the recommended size criteria.

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 thyroid nodule with atypia of undetermined significance was denied, the published record says the denial is worth fighting.