Medicine Serv Proc denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that a patient has requested reimbursement for (1) external mobile outpatient cardiovascular telemetry with review and interpretation and/or (2) the external mobile outpatient cardiovascular telemetry with technical support. The medical records document impaired cardiac responses on autonomic testing. Continuous mobile outpatient cardiovascular telemetry would have been more effective than an event monitor in this setting because it can detect clinically relevant arrhythmias that may occur without symptoms or patient activation. Given the patient’s presentation and prior testing, continuous telemetry was likely to have been more beneficial for evaluating the patient’s condition than standard monitoring.

Findings: The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) services.The records show that the patient has treatment‑resistant major depressive disorder, post‑traumatic stress disorder (PTSD), somatization disorder, and cognitive deficits. The patient has failed multiple prior treatments, including antidepressants, adjunctive medications, IV ketamine, and intranasal ketamine. After a comprehensive evaluation, the provider recommended accelerated intermittent theta‑burst TMS due to the severity of treatment resistance. Accelerated TMS protocols, which involve multiple daily sessions, have demonstrated efficacy comparable to once‑daily repetitive TMS and may offer faster symptom improvement.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for applied behavior analysis (ABA) services.Based on the information provided, the ABA Practice Guidelines from the Council of Autism Service Providers (CASP), the Model Policy Coverage from the ABA coding Coalition, and Papatola and Lustig's medical necessity criteria, the requested ABA services are not medically necessary for the treatment of this patient. The patient’s provider requested a comprehensive number of hours, but a limited number of goals were addressed in the treatment plan. Per the CASP guidelines, “Treatment intensity should reflect the complexity, breadth, and depth of treatment targets, as well as the environment, treatment protocols, and significance of patient needs.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for an increase of hours of applied behavior analysis (ABA) in-home therapy. Based on the provided medical records, the ABA Practice Guidelines from the Council of Autism Service Providers (CASP), the Model Policy Coverage from the ABA Coding Coalition, and the medical necessity criteria established by researchers, an increase in ABA therapy of additional hours of 1:1 therapy per week is not indicated for this patient. The requested increase of ABA therapy is not supported by any additional documentation. Therefore, the request does not meet several essential practice elements of ABA. Without data or goals, it is unclear how the additional hours per week will be utilized.

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 medicine serv proc, then check the rights and deadlines that apply to your plan.