Lipoprotein-associated Phospholipase A2 Testing denials in California external review

What the reviewers wrote

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing components (lipoprotein-associated phospholipase A2) and/or (apolipoprotein B).Findings: The physician reviewer found that here is lack of clinical studies demonstrating that advanced lipoprotein testing adds significant actionable information to information yielded with a basic fasting lipid panel. Harada and colleagues noted that the American Heart Association (AHA) and American College of Cardiology (ACC) guidelines do not issue any recommendation for advanced lipoprotein testing.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing CPT code 83698 and CPT codes 82172, 83695, 83701, and 83701-59 performed on a separate date of service. Findings: The physician reviewers found that in this circumstance, prevention guidelines for the management of cardiac risk and dyslipidemia have been established. These guidelines are periodically updated by expert committees and are endorsed by several national organizations.

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 Lipoprotein-associated Phospholipase A2 Testing, then check the rights and deadlines that apply to your plan.