Advanced Lipoprotein Testing denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a blood test (advanced lipoprotein testing). This patient has a history of hyperlipidemia and silent stroke. Despite the proven clinical utility of standard lipid testing for risk management, there remains a significant burden of atherosclerotic cardiovascular disease (ASCVD) events that remain unaddressed. Meanwhile, there is sufficient support in the medical literature demonstrating the incremental benefit of various advanced lipoprotein tests as independent risk factors with the potential to influence pharmacologic treatment decisions.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a blood test (advanced lipoprotein testing). Professional society guidelines do not advocate routine advanced lipoprotein testing given the predominance of risk assessment and management based on traditional lipid levels. However, advanced lipoprotein testing may be utilized in patients deemed to be at borderline 10-year risk of arteriosclerotic cardiovascular disease (ASCVD) events, as reported in this patient’s case. In such clinical settings, the American College of Cardiology (ACC) has indicated that elevated apolipoprotein B or lipoprotein (a) levels are risk enhancers that favor beginning statin drug therapy, while normal levels support deferring such therapy. Using the ACC risk calculator, this patient’s 10-year ASCVD risk is borderline.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient presented for a cardiovascular risk assessment evaluation secondary to a diagnosis of dyslipidemia. The most recent cholesterol level is 209, with low density lipoprotein (LDL) of 114 and high density lipoprotein (HDL) of 78. The patient denied associated symptoms, including decreased activity or exercise tolerance, shortness of breath, swelling, or chest pain. There was no documented history of hypertension or diabetes. The patient was educated and following a low carbohydrate, low fat diet, and exercising five to six times per week. She was referred for advanced lipoprotein testing including lipid particle number and sizing for further risk stratification.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollee who presented to her provider for examination.Findings: The physician reviewer found that the patient had advanced lipoprotein analysis as part of a medical evaluation for lifestyle alterations. The values obtained showed increased cholesterol as well as abnormal values on the sub-fractions such as low density lipoprotein particle count. The patient has requested reimbursement for advanced lipoprotein testing. The Health Plan denied this request for reimbursement and reported that the services at issue were investigational for the evaluation of this patient’s medical condition. There is insufficient data to support the use of advanced lipoprotein testing in this clinical setting.

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 Advanced Lipoprotein Testing, then check the rights and deadlines that apply to your plan.