Neurology Consultation denials: what the review data shows

Where the denial was overturned

Findings: The physician reviewer found that the patient has requested authorization and coverage for tertiary level of care consultation with neurology. This case highlights the importance of comprehensive care for adults with cerebral palsy, particularly when multiple associated conditions such as cervical spondylosis, hypothyroidism, and opioid dependence are present. The National Institute for Health and Care Excellence (NICE) guidelines on the management of cerebral palsy in adults, specifically, section 1.1.1, recommends the referral of adults with cerebral palsy to a multidisciplinary team experienced in the management of neurological impairment if their ability to carry out their usual daily activities deteriorates or a neurosurgical orthopedic procedure is being considered that may affect their ability to carry out their usual daily activities.

The patient has requested authorization and coverage for acute hospitalization until a definitive diagnosis is determined; subacute hospitalization thereafter for the duration of recovery; one-on-one sitter to monitor risk of aspiration with oral suctioning; physical therapy; occupational therapy; speech therapy; a gastroenterology consultation/second opinion; neurology consultation/second opinion; an otolaryngology consultation/second opinion; a neuro-oncology consultation/second opinion; and/or a cardiology consultation. Based on the available documentation, this patient’s vomiting could be multifactorial due to her chronic medical conditions. The cause for her intractable vomiting has not been determined. The patient has been treated for gastroparesis with placement of a J-tube, consistent with the recommendations from the American College of Gastroenterology (ACG).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for in-person evaluation and treatment by a neurologist at the skilled nursing facility (SNF). Patients in vegetative states can show behaviors such as spontaneous eye opening, but may still fail to demonstrate behavioral signs of consciousness. Findings of even minimal awareness may favorably alter prognosis and influence management such as pain management and rehabilitation interventions. Early signs of recovery of consciousness include visual pursuit and automatic movements, which requires assessment measures sensitive to these findings. Potentially confounding conditions should be ruled out and interventions to optimize arousal are appropriate for patients in persistent vegetative states. Neurologists or rehabilitation specialists generally best conduct this evaluation and management.

A 52-year-old female has requested coverage for a consultation with a neurologist for treatment of her leg weakness, dystonia and stiff-person syndrome. Findings: The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. This patient has had a progressive neurologic condition, with a variety of diagnoses entertained by different consultants. There have been conflicting features, but significant evidence of autoimmunity. She has been evaluated and treated at tertiary care centers, and she has requested an additional opinion by a community neurologist. There is no evidence that a seventh opinion is needed. In this patient’s case, the clinical picture of autoimmunity with anti-GAD antibodies may still represent stiff-person syndrome.

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 Neurology Consultationwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.