Ongoing OON Tx denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the insertion of a hepatic artery infusion pump. In a meta-analysis of the comparative effectiveness of hepatic artery based therapies for unresectable colorectal liver metastases, researchers conclude, “Hepatic arterial infusion, radioembolization, and transcatheter arterial chemoembolization are equally effective in patients with unresectable colorectal liver metastases with marginal differences in survival.” The National Comprehensive Cancer Network (NCCN) guidelines on the management of colon cancer note that clinical trials have shown a trend toward prolonged long-term survival with hepatic arterial infusion of chemotherapy, noting that hepatic artery infusion plus or minus systemic 5-FU/leucovorin is an option at institutions with experience in both surgical and medical oncologic asp…

The patient’s parent has requested authorization and coverage for hip to ankle scanogram/EOS imaging. The Health Plan denied the request and reported the requested services are not medically necessary for the evaluation of this patient. Researchers concluded that the “identification of congenital and acquired etiologies causing alignment disorders and leg-length discrepancies (LLD) in children is important for management.” Per the authors, “LLD of greater than 1 cm can cause altered biomechanics, resulting in scoliosis, back and lower extremity joint pain, pelvic tilt, abnormal gait and premature degenerative joint disease.” Medical literature states “upright EOS protocols that utilize a faster speed and lower current are more accurate than CT scanograms and conventional radiographs for the assessment of length and also are associated with a significantly lower radiation exposure.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for services on the basis that the services were necessary for treatment of an emergency medical condition. The records show that the patient has a history of limbic encephalitis, muscle weakness, cognitive dysfunction, and was manifesting obsessive-compulsive disorder behaviors. The patient was brought to the emergency room on several occasions. The patient was admitted with four-point restraints due to severe aggressive outbursts, behavioral changes, altered level of consciousness, amnesia, schizophrenia, tic disorder, and a low suspicion of pediatric acute-onset neuropsychiatric syndrome (PANS). Seeking a second opinion, the patient and his family consulted several providers.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Shoemaker Protocol including office visit with qualified provider experienced with the Shoemaker Protocol once every four to six weeks until the Shoemaker Protocol is completed; Welchol 625 mg; liposomal vitamin C 500 mg; vasoactive intestinal peptide nasal spray; epinastine HCL 0.05% two drops twice daily; neuroquadrant magnetic resonance imaging (MRI) without contrast; macron biofilm analysis; nares culture; Singulair 10 mg once daily; Cromolyn 4 ampules twice daily; and cholestyramine non-saccharine 4 grams. CRIS is a controversial constellation of symptoms, which is not currently accepted as a diagnostic disorder.

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 Ongoing OON Tx, then check the rights and deadlines that apply to your plan.