Viral Infection denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for genetic testing (cytogenomic SNP microarray). The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollee’s congenital cytomegalovirus and developmental delay. At issue in this case is whether the requested genetic testing (cytogenomic SNP microarray) is medically necessary for treatment of the patient’s medical condition.Per researchers, the clinical utility of chromosomal microarray (CMA) is well established. CMA is now considered first-line genetic testing for individuals with developmental delays and autism spectrum disorders. It is important to note that CMA technology has been shown to provide clinically actionable information.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Findings: The physician reviewer found that acute respiratory syndrome coronavirus-2 (COVID-19) is a novel ribonucleic acid (RNA) coronavirus that is the etiologic agent responsible for the current pandemic. This virus typically causes flu-like symptoms, and can progress to severe acute respiratory failure, and multiorgan failure. There is currently no pharmacotherapeutic agent that is proven to be effective treatment for COVID-19 infection. Treatment is largely supportive, including managing symptoms, trying to prevent ventilatory failure, and preventing complications, as well as avoiding transmission to others.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for all or any long-term acute care hospital (LTACH) - intensive care unit (ICU) services. Barker-Davies and colleagues report that while long-term sequelae of COVID-19 are unknown, evidence from previous novel coronavirus outbreaks demonstrate impaired pulmonary and physical function, reduced quality of life, and emotional distress. The authors further report that rehabilitation of COVID-19 survivors requiring critical care who may develop psychological, physical and cognitive impairments should be tailored to individual patient needs. Barlow and colleagues note that there is currently no widely accepted standard of care in the pharmacologic management of patients with COVID-19.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage computed tomography (CT) scan to measure calcium in the coronary arteries. Primary prevention of arteriosclerotic cardiovascular disease requires attention to prevention and management of arteriosclerotic cardiovascular disease risk factors. Elevated serum cholesterol, usually defined by low-density lipoprotein (LDL) cholesterol, is a major arteriosclerotic cardiovascular disease risk factor. A patient’s 10-year arteriosclerotic cardiovascular disease risk should guide therapeutic considerations in patients ages 40 to 75. The higher the estimated arteriosclerotic cardiovascular disease risk, the more likely the patient will benefit from evidence-based statin treatment.

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 viral infection, then check the rights and deadlines that apply to your plan.