CT 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 a CT scan.Findings: Two of the three physician reviewers found that the CT scan that was performed was likely to be more beneficial for treatment of the patients condition than any other available standard therapy. Medical literature supports the use of CT imaging to screen for malignancy in patients with dermatomyositis. The association between dermatomyositis and internal malignancy is well established. Their data suggests that effective malignancy screening of dermatomyositis patients often requires evaluation beyond a history, physical examination, and age-appropriate cancer screening. An extensive search for malignancy, particularly computed tomographic scans, may be warranted in at least a subset of patients with dermatomyositis and risk factors of malignancy.

A 64-year-old female enrollee requested authorization and coverage of a CT scan for the treatment of an 8 mm well circumscribed left upper lobe lung nodule. The Health Plan denied the enrollee’s request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plan’s denial on the basis that the requested service is medically necessary for treatment of the patient’s medical condition.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has reimbursement for computed tomography (CT) scan. The submitted documentation does not support the medical necessity of the patient’s CT scan in a hospital outpatient setting. According to researchers a CT scan is beneficial in diagnosing patients with abdominal pain and is considered the first-line imaging modality for this indication. There are several diseases with nonspecific symptoms that cannot be diagnosed with a physical examination alone. In such cases, CT is the most sensitive diagnostic method for diagnosis. CT has also become a primary imaging test for the evaluation of the small bowel and is especially beneficial in the diagnosis of Crohn’s disease and ulcerative colitis, which are possible explanations for the patient’s symptoms in this case.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a computed tomography (CT) scan or magnetic resonance spectroscopy (MRS) or angiography and magnetic resonance angiography (MRA) scan. The Health Plan has denied this request indicating that the requested diagnostic procedures are not medically necessary for evaluation of the enrollee’s dizziness. The requested for CT scan, MRS or angiography and MRA scan are not medically necessary for evaluation of the patient’s medical condition. In this case, the patient has a history of dizziness without evidence of other neurologic deficits. Symptoms have been present for at least four years, and the patient has been seen by a neurologist, who did not detect an underlying disease. In addition, the patient underwent an MRI of the brain in 2016 which was negative.

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