Alternative Tx denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 46-year-old female with idiopathic gastroparesis, gastroesophageal reflux disease, chronic abdominal pain and constipation. She had an extensive gastrointestinal work up which identified negative lower esophageal sphincter tone and severe gastroparesis. The patient has daily symptoms of reflux and regurgitation and has had multiple hospitalizations for recurrent abdominal pain, nausea, vomiting and dehydration. She was treated with Propulsid when the drug was available and Reglan until she developed an allergy to the drug. The patient failed treatment with erythromycin but was started on Zelnorm with some improvement in her symptoms of abdominal pain and constipation. She has still required hospitalization for recurrent abdominal pain, nausea and vomiting, failure to thrive, line sepsis and deep vein thrombosis.

Physician 1: The patient is a 16-year-old female with a history of pelvic/groin pain. She has migratory pain in the lower abdominal quadrants and groin, right side greater than left. The pain is constant and always present, but can increase to as high as 7/10. She also complains of shoulder pain. She has a history of chronic bilateral frontal headaches, reported as migraines. She has undergone extensive workup in the past for the cause of her pain. Workup included multiple negative laboratory examinations, CT scans and abdominal pelvic ultrasounds. It also included extensive physical evaluations by multiple physicians. The patient has been evaluated and treated by a psychotherapist who feels no significant psychopathology is present. She has taken multiple medications including large doses of neuropathic pain medications such as Neurontin, trileptal, lidocaine and Ultram.

Where the denial was upheld

Physician 1: The patient is a 31-year-old female who is requesting authorization for vagus nerve stimulation (VNS) treatment for major depression. The patient has not shown sustained improvement with conventional anti-depressants and electroconvulsive (ECT) therapy. The Health Plan has denied the patient’s request indicating VNS therapy is investigational and therefore not a covered benefit.To date, VNS remains a highly controversial treatment for refractory depression. There are no valid, controlled, double-blind, research centered and clinically based reproducible studies showing that VNS is any better than sham treatment. VNS is not a part of established principles of health care practice as of this date for the management of refractory depression. VNS remains an experimental, controversial and unproven procedure at this time.

Physician 1: The patient is a 37-year-old female with an extensive history of mental illness. She has been diagnosed as having major depression with psychotic features and/or schizoaffective disorder, and has tried numerous psychotropic medications which include Geodon, Wellbutrin, Effexor, Seroquel, Risperdal, Lorazepam, Lamictal, Cymbalta, Celexa, Depakote and Xanax along with electroconvulsive therapy (ECT). According to the patient and her provider, she has had adequate trials of the various treatments. The patient currently has depressed mood, crying spells, anxiety, disturbed sleep, disturbed concentration and feelings of hopelessness/helplessness with suicidal ideation. Her current regimen of medications is not helpful. The patient, as well as her provider, feels that they have exhausted all available treatment alternatives.

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 alternative tx, then check the rights and deadlines that apply to your plan.