Cardiovascular Procedures 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: An enrollee has requested authorization and coverage for transcatheter tricuspid valve replacement procedure with associated one (1) day inpatient stay. Tricuspid regurgitation is a common valvular problem and historically has not been treated as aggressively as left-sided valvular disease. Tricuspid regurgitation can be primary or secondary and poses a challenge in clinical practice. Surgical intervention of tricuspid regurgitation has traditionally been avoided due to higher rates of morbidity and mortality associated with isolated tricuspid valve intervention. The only medical management is diuretics, which help with volume overload but do not fix the underlying tricuspid regurgitation. Newer transcatheter-based treatments offer less risky and perhaps equally beneficial options compared to surgery.

Physician 1: The patient is a 39-year-old female with primary autonomic insufficiency which is manifest by disabling orthostatic hypotension and bilateral tonic pupils. There is reported confirmation of the diagnosis with a positive ganglionic acetylcholine receptor antibody test. The patient has failed standard therapy including midodrine and Florinef and is requesting authorization for a treatment protocol which involves plasmapheresis, prednisone and Imuran. The Health Plan considers the proposed therapy experimental/ investigational and denied the request for authorization and coverage.This patient has a subacute, chronic autonomic insufficiency and has undergone an extensive work-up; no other treatable disorder has been identified. She has been diagnosed with primary autoimmune autonomic failure and there is no known standard therapy for this disorder.

Where the denial was upheld

Physician #1: The patient is a 52-year-old female who has had telangiectasias and recurrent varices, which initially started when she was 24, and was treated with sclerotherapy. She has now experienced a recurrence with mild swelling and heaviness symptoms. The patient’s duplex exam did not show any greater saphenous vein (GSV) reflux in either leg, only a localized area of reflux on the left leg, which it seems is not intended to be addressed with the proposed treatment. At issue is whether sclerotherapy with topical laser ablation as suggested by the patient’s physician is likely to be more beneficial than standard therapy.Telangiectasias and small reticular veins are generally considered to be cosmetic, though they sometimes may cause symptoms as has occurred in this case.

Physician 1The patient is a 48-year-old female who presents with progressively painful right calf varicosities. She has a family history of veins on her grandmother’s side. She has mild lymphedema, which could be a result of cellulitis. She also had knee surgery, which may have contributed to this swelling. She has no past history of problems with her veins with no bleeds, phlebitis or thrombosis. The physician’s clinical exam suggested she had bulging varicosities in the right anterolateral and medial thigh as well as the proximal right calf; all from the greater saphenous vein access. Duplex imaging suggested there was saphenofemoral junction incompetence. The patient was offered therapy, which could be surgical ligation and stripping, endovenous laser ablation or ultrasound directed sclerotherapy. The patient has not had any compressive stocking therapy to ameliorate her symptoms.

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 cardiovascular procedures, then check the rights and deadlines that apply to your plan.