Afirma Gene Expression Classifier Test denials in California external review
In the California DMHC record, independent physician reviewers decided 13 published external-review cases involving Afirma Gene Expression Classifier Testand 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.
Conditions behind Afirma Gene Expression Classifier Test denials
| Category | Decisions | Overturned |
|---|---|---|
| Thyroid Nodule With Atypia Of Undetermined Significance | 6 | 100% |
| Thyroid Nodule With Indeterminate Cytology | 3 | 100% |
What the reviewers wrote
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 for evaluation of the enrollee’s indeterminate thyroid nodule.Findings: The physician reviewer found that The patient was diagnosed with a 1.5 cm right sided thyroid nodule. A fine needle aspiration (FNA) biopsy yielded atypia of undetermined significance. A specimen was subsequently sent for Afirma gene classifier analysis. The patient has requested reimbursement for the Afirma gene expression classifier test. The Health Plan denied reimbursement on the basis that the services at issue were investigational for the evaluation of this patient. While 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 indeterminate (Alexander, et al).
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 treatment 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 Afirma Gene Expression Classifier Test, 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