Diag/ MD Eval denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast implant removal, bilateral capsulectomy, bilateral breast reconstruction, and bilateral reinsertion of breast implants to be performed in one surgical procedure. Researchers state that traditionally, “capsular contracture is treated surgically, although it is important to note that treatment is only indicated in grades III and IV capsular contracture. The Baker classification describes four grades of capsular contracture, with grade I being a normal, soft breast; grade II being a minimally firm breast; grade III being a moderately firm breast with some visible deformity; and IV being a painful, hard, distorted breast. Grade III and IV contractures typically require surgical management.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for medication management appointments once every two weeks through 2024 and/or one hour per week of one-to-one dialectical behavior therapy (DBT). Findings: The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for referrals to head and neck surgery, maxillofacial surgery, chiropractic, cardiology, pulmonology and a bone density test for evaluation of the enrollee’s neck pain, back pain, chest pain, and headaches. Findings: The physician reviewer found that with regard to the request for referral to head and neck surgery and referral to maxillofacial surgery, the records indicate that the patient was previously evaluated by a head and neck surgeon. This evaluation included a history, an examination, an assessment and plan. The provider did not find that the patient was a candidate for any surgical intervention and recommended treatment with corticosteroid nasal spray and salt water nasal spray. Further, the patient had subsequent imaging of the sinuses and nasal septum both with CT and MRI.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for services with a tertiary level of care physician who is dually board certified in both obstetrics and gynecology and reproductive endocrinology and infertility. Reproductive endocrinology and infertility medicine is a subspecialty of obstetrics and gynecology. As the name suggests, and according to the American Board of Obstetrics & Gynecology (ABOG), this subspecialty focuses on complex reproductive disorders. This may include the surgical management of these conditions. However, it should be noted that physicians in the field of general obstetrics and gynecology (OB/GYN) also manage a wide range of conditions on a routine basis.

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 diag/ md eval, then check the rights and deadlines that apply to your plan.