Thyroid Problems: 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 the Afirma gene expression classifier testing for evaluation of the enrollee’s follicular lesion of undetermined significance. Findings: 2/3 of the physician reviewers found that there are multiple peer reviewed scientific articles supporting the benefits of genetic testing in thyroid nodules. The cytopathology result of the 5.0 cm thyroid nodule was consistent with AUS. The risk of malignancy is 5-15% in AUS. The American Thyroid Association’s guidelines state that for nodules with AUS 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.

The patient is a 53-year-old female who was found to have a nodular thyroid by her gynecologist and was referred for a confirmatory ultrasound. The patient consulted an endocrinologist/thyroidologist in July 2005. She had been on lithium for nine years and apparently had a normal TSH a year prior to the visit, a low TSH in May 2005, and another subsequent TSH level that was said to be high. According to the initial office notes, the patient complained of a 30-pound weight gain and insomnia. The initial laboratory evaluation revealed normal T3 and T4 levels, a suppressed TSH level, an elevated thyroglobulin, and multiple negative thyroid antibodies. There are no notes documenting the full extent of the provider’s initial physical examination.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a parathyroid allotransplant procedure. Hypoparathyroidism describes underactive parathyroid gland function, which results in deficiency of parathyroid hormone (PTH) production. The role of PTH is to regulate blood calcium levels. Without adequate PTH production, calcium levels decline, resulting in hypocalcemia, which causes variable symptoms including muscle cramps, a tingling sensation around the mouth or in the extremities, weakness, seizures, brain fog, irregular heartbeats, and in some cases, deposits of soft tissue calcium in the brain, kidney, joint, eyes, skin and blood vessels. Long-term uncontrolled hypoparathyroidism may lead to skeletal abnormalities that can affect bone strength, leading to a higher risk of bone fractures.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for MyoCycle home functional electrical stimulation (FES) cycling therapy system. The evidence for the effectiveness of functional electrical stimulation (FES) cycling in people with nerve damage such as brachial plexopathy, neuropathy, multiple sclerosis, and other neurological conditions such as stroke, brain injury and spinal cord injuries is limited. There is insufficient evidence in current medical literature supporting the requested equipment as effective for this patient in terms of long-term improvement of muscle strength, vascular blood flow, bone mineral density, reduction of spasticity and atrophy, facilitation of functional motor movement, or reduction muscle atrophy in the upper and lower extremities.

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