Thyroid Nodule With Indeterminate Cytology denials in California external review
In the California DMHC record, independent physician reviewers decided 23 published external-review cases involving thyroid nodule with indeterminate cytologyand overturned the plan’s denial in 100%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for thyroid nodule with indeterminate cytology
| Category | Decisions | Overturned |
|---|---|---|
| Afirma Gene Expression Classifier | 8 | 100% |
| Afirma Gene Expression Classifier Testing | 5 | 100% |
| Afirma Gene Expression Classifier Test | 3 | 100% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the Afirma Gene Expression Classifier (GEC) molecular test for evaluation of the enrollee’s thyroid nodule. Findings: Two of the physician reviewers found that While a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority turn out to be benign. Afirma utilizes a GEC in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ThyraMir gene test. Findings: The physician reviewers found that the Bethesda System recommends a repeat thyroid biopsy. Moreover, the newest 2015 American Thyroid Association's guidelines state that “for nodules with AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat fine needle aspiration (FNA) or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making”.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 thyroid nodule with indeterminate cytology, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY