Computed Tomography Scan denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography scan provided on 2/07/18. The Health Plan has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollee’s concussion. A very common and widely researched issue confronted by emergency rooms nationwide is the over-utilization of CT scans for patients with relatively minor head trauma. There are several programs available to help triage these patients. In an article written by Haydel in 2000, “The authors concluded that CT was indicated in all patients with minor head injury.

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for a computed tomography (CT) scan of the left foot. Findings: The physician reviewer found that the gold standard in the diagnosis of gout is demonstrating uric acid crystals in the joint fluid or in tophi. Bony alterations occur only years into the illness and even then, only 45% of patients have radiographic findings. Further confusing the issue is that hyperuricemia can occur in patients who do not have gout. Early diagnosis is important, as uric acid lowering medications can play a role in preventing functional impairment. Over the years, various modalities have been developed to more accurately diagnose gout Historically, radiographs have been the mainstay of imaging, but only demonstrate chronic (irreversible) changes.

Where the denial was upheld

The parent of a 10-year-old male enrollee has requested authorization and coverage for a computed tomography (CT) scan for treatment of the enrollee’s costochondritis and mild persistent asthma. Findings: The physician reviewer found that Hussain and colleagues note that chest pain is a reasonably common complaint in the pediatric population. In terms of referral to pediatric cardiology, it ranks second only to heart murmurs. The most common cause is idiopathic, occurring in up to half of cases. Other causes include pulmonary, musculoskeletal, gastrointestinal, and psychological. Actual cardiac causes are present in less than five percent of cases. Most children have normal physical exam findings.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) scan, positron emission tomography (PET) scan, biopsy and pathology for evaluation of the enrollee’s neck pain, hearing loss, rhinitis, and nasal polyp. Findings: The physician reviewer found that the medical literature, PET/CT imaging can have a substantial impact on intended management when used for three targeted diagnostic indications: (1) determining whether a suspicious lesion is cancer; (2) detecting an unknown primary tumor site in a patient with confirmed or strongly suspected metastatic disease; and (3) detecting a primary tumor site in a patient with a presumed paraneoplastic syndrome. PET/CT plays a crucial role in the diagnosis and management of patients with head and neck squamous cell cancer (HNSCC).

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 Computed Tomography Scan, then check the rights and deadlines that apply to your plan.