Cholesterol Screen denials in California external review
In the California DMHC record, independent physician reviewers decided 13 published external-review cases involving Cholesterol Screenand overturned the plan’s denial in 0%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Cholesterol Screen denials
| Category | Decisions | Overturned |
|---|---|---|
| High Cholesterol | 3 | 0% |
What the reviewers wrote
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for cardiac marker laboratory testing for the stated condition of family history of high cholesterol. The American College of Cardiology (ACC) as well as the American Heart Association (AHA) guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of LDL, HDL subclasses, lipoprotein(a), lipoprotein(b), C-reactive protein, high sensitivity CRP, insulin, insulin resistance, fibrinogen, genetic testing, and homocysteine.
Findings: The physician reviewer found that the patient requested reimbursement for Apolipoprotein testing. The American College of Cardiology (ACC) as well as the American Heart Association (AHA) guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phosholipase A2 (Lp-PLA2), sub-classifications of LDL, HDL subclasses, lipoprotein(a), lipoprotein(b), C-reactive protein, high sensitivity CRP, insulin, insulin resistance, fibrinogen, genetic testing, and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcomes incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.
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 Cholesterol Screen, 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