Durable Medical Equipment denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a three-year-old male with spinal muscular atrophy and a history of multiple hospitalizations for pneumonia and atelectasis. He is G-tube dependent and has difficulty with oral secretions. He has been treated with multiple aerosols as well as the Cough Assist machine, the Vest system and oral suctioning. He cannot tolerate chest physical therapy (CPT) because he is resistant to postural drainage. At issue in this case is whether the Vest system is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.This patient will require aggressive pulmonary disease preventative treatment for life. He is resistant to postural drainage treatment and has done well with the Vest system.

Physician 1: The patient is a 45-year-old woman who has had diabetes since the age of 10 with long standing symptoms of nausea and vomiting from gastroparesis, particularly at night. She also has hypertension. Currently, she is maintained on an insulin pump. She has failed to have improvement with conventional therapy and has used domperidone without improvement. The patient underwent endoscopy (which did not demonstrate an anatomic cause for symptoms) with injection of Botox into the pylorus (which did resolve her symptoms). She has had an abnormal, delayed gastric emptying study on two occasions and an electrogastrogram performed in February 2004 was abnormal. A trial of Enterra therapy has been recommended.

Where the denial was upheld

Physician 1: The patient is a 39-year-old man with long history of depressive disorder resistant to multiple antidepressant medications and some medication combinations. He has had multiple psychiatric hospitalizations for treatment of depression and associated suicidal ideation. ECT treatments have not been of consistent benefit, both bilateral and unilateral series with monthly maintenance. A review of documents seems to indicate that mono-amine oxidase inhibitors (MAOI) are the only class of antidepressant medications that have not been utilized. The patient has requested authorization for vagus nerve stimulation (VNS) therapy to treat his depression.

Physician 1: The patient is a 50-year-old female with a history of Major Depression, recurrent, referred for placement of a vagus nerve stimulator (VNS) after she was felt to be treatment refractory to Effexor, Wellbutrin, Provigil, Zyprexa, and Seroquel. Review of her psychiatrist’s treatment notes indicate his first being consulted by the patient in 1999 at which time she was diagnosed as suffering from Major Depression, attendant with neurovegetative disturbances consistent with the diagnosis. At this point, she had begun a starter pack of Effexor. Her first follow-up appointment thereafter was a month later, at which time she was noted as “getting some more energy. Not been crying as much anymore and feels more confident.” Her Effexor XR was then changed to 75 mg twice a day.

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 durable medical equipment, then check the rights and deadlines that apply to your plan.