Formulary V Non Form denials: what the review data shows

Where the denial was overturned

The patient is a 50-year-old male with a history of chronic sinusitis. He had maxillary advancement surgery in 1982. There is a questioned history of Caldwell-Luc sinus surgery in 1990. In 1992, the patient underwent right-sided functional endoscopic sinus surgery. In 2000, he continued with chronic sinusitis symptoms. Medical therapy has included allergy shots, multiple nasal steroid sprays, Atrovent, Astelin, Singulair, multiple oral antihistamines, oral steroids, Kenalog injections, in addition to multiple antibiotics. The patient subsequently underwent revisional functional endoscopic sinus surgery, septoplasty, and turbinate reduction surgery. Despite multiple surgical interventions and aggressive medical therapy he still continues to experience episodes of sinusitis. He was treated with a course of Rocephin in 2002.

The patient is a 61-year-old female with reactive airway disease, IgE mediated rhinitis, chronic sinusitis and seasonal and perennial allergies related to mite, mold and animal dander. She has moderate to severe asthma which is steroid dependent and her condition is deteriorating. The patient also has an evolving depression that is situational, secondary to her chronic allergic disease and its effect on her lifestyle and well-being. Her provider’s note of July 2006 indicates she is broadly allergic, mostly housebound and unable to tolerate therapeutic dosages of immunotherapy. The proposed treatment involves stabilization with Xolair over several months followed by immunotherapy. If the immunotherapy is better tolerated and she is able to reach maintenance status, the Xolair could be tapered off after six to twelve months.

Where the denial was upheld

The patient is a 48-year-old female who is perimenopausal and was referred for a DEXA scan because of a positive family history of osteoporosis. This scan of the left and right hips revealed T scores of -2.3 and -2.5. The etiology of the low bone density is unknown and a presumptive diagnosis of osteoporosis was suggested by the patient’s provider. Based on a history of multiple sclerosis, petit mal seizures and a family history of osteoporosis, the patient was considered to be at high risk for falls. She was fitted with a hip protector and instructed to return in a year for another DEXA scan. There is no history of fragility fractures and no additional risk factors beyond her T scores and the possibility that she might fall.

The patient is a 32-year-old male with apparently well-documented cutaneous psoriasis, with extensive involvement of trunk and all four limbs. Records from his dermatologist and his primary physician make only one mention that “the arthritis still affects the knees and the ankle joints,” and this is not described elsewhere in the record. The dermatologist states that the patient has failed trials of Soriatane, oral prednisone, and topical triamcinolone, and further notes that methotrexate is contraindicated because the patient drinks alcohol. Nonetheless, the dermatologist’s last note of 1/30/04 states the patient has been started on methotrexate 7.5mg per week.The diagnosis of psoriatic arthritis is not established by the medical records. Cutaneous psoriasis itself is obviously very common, and is appropriately managed by dermatologists.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Formulary V Non Formwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.