Electrical, Thermal & Radiofrequency Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 33-year-old male with obstructive sleep apnea. He was prescribed a trial of nasal CPAP, but has had difficulty sleeping with this for longer than three hours a night. He noted that his nasal passages are quite obstructed. Examination previously had revealed the presence of engorged inferior turbinates and the patient did undergo a trial of Nasonex nasal spray. As the patient was failing in his trial of CPAP and had failed a trial of medical therapy for his nasal congestion, turbinoplasty was undertaken. The method chosen for this procedure was radiofrequency ablation. According to the surgeon’s notes, this procedure was performed in treatment of hypertrophy of the inferior turbinates. The patient was also referred for evaluation for the creation of a dental appliance for further treatment of his sleep apnea.

Physician 1: The patient is a 35-year-old female with bilateral symptomatic varicose veins, worse on the right, with lipodermatosclerosis on her left calf. She has undergone phlebectomy and VNUS closure on the right leg in the past. The patient now has reflux on both legs, with 15 mm varices on the right from the mid-thigh down, and 6 mm varices on the left with reflux. The patient is very symptomatic with skin changes on the right leg, and has used compression stockings for years. The patient’s provider proposed endovenous laser therapy (EVLT) for treatment of the patient’s left leg and possible sclerotherapy on the right leg. The Health Plan has denied authorization and coverage for EVLT on the basis the requested procedure is considered investigational.Review of the relevant data demonstrates EVLT is not an investigational device.

Where the denial was upheld

Physician #1: The patient is a 54-year-old male who presented with rectal bleeding in May 2004. He was found to have a 5.0cm circumferential rectal cancer. The CT scan showed a 3.5cm lesion in the liver which was positive on PET scan leading to a diagnosis of stage IV adenocarcinoma of the rectum. He was treated with chemotherapy (FOLFOX plus Avastin) and had a resection of his rectal carcinoma. There was a second operation with resection of his liver metastases and a second round of chemotherapy (FOLFOX) and radiation. A CT scan in July 2005 showed a mass in the right lung. A repeat CT scan and a PET scan showed three nodules in the right lung and one nodule in the left lung. In October 2005 the patient underwent right lower lobectomy and resection of the right middle lobe nodule. The pathology report showed metastatic adenocarcinoma in each specimen.

Physician 1The patient is a 53-year-old female with numerous upper gastrointestinal complaints with no evidence of complicated GERD (e.g., esophagitis, stricture, Barrett’s syndrome). There is mild reflux physiology without evidence of a hiatal hernia, and an ambulatory pH study showing upright reflux only, not supine. There are possibly other aggravating factors, such as gastroparesis, making symptom response difficult to judge. Additionally, the patient has functional elements including non-obstructive dysphagia and medication intolerance. The patient has requested authorization to undergo the Stretta procedure.

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 electrical, thermal & radiofrequency therapy, then check the rights and deadlines that apply to your plan.