Ophthalmology Proc denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization coverage for eyelid surgery (CPT 67908 – repair blepharoplasty conjunctive-tarso-muller’s muscle-levator resection (1 unit) and CPT 15823 – blepharoplasty upper eyelid with excessive skin (1 unit)) for treatment of the enrollee’s bilateral dermatochalasis and myogenic ptosis. Findings: The physician reviewer found that upper eyelid ptosis can lead to functional impairment requiring surgical repair.

An enrollee has requested reimbursement for vision therapy. Current concepts in convergence insufficiency describe this as a condition in which an individual has difficulty with reading “at near” because of their inability to bring their eyes close together. Colleagues have noted that convergence insufficiency can develop following head trauma. While the standard treatment for patients with convergence insufficiency would be to start with home-based exercises including pencil push-ups, studies such as the Comparison of Three Vision Therapy Approaches by colleagues have shown that it is not unreasonable to start office-based vision therapy, which has also been shown to be effective. In this case, the patient’s initial examination clearly documented objective evidence of convergence insufficiency. The patient’s near point of convergence was at and exophoria was also noted.

Where the denial was upheld

Physician 1: The patient is a 58-year-old female with an asymptomatic pterygium in the left eye. She was referred to an ocular surgeon for evaluation and excision of the lesion. The specialist recommended reconstruction of the ocular surface with an amniotic graft after excision, and a request for authorization was submitted to the Health Plan. The Health Plan considers this an investigational procedure and authorization was denied.There is no peer-reviewed evidence that pterygium excision with amniotic membrane transplantation is superior to any currently recognized surgical modalities. Although amniotic membrane graft is a recognized and accepted procedure, it has not yet become the standard of care. In a fairly routine situation such as this one, a more established surgical technique offers the best outcome for the patient.

Physician 1: The patient is a 66-year-old female who has a history of melanoma of the right eye. She also had degenerative eyesight. In August 2004, a Heidelberg retinal test was performed to rule out glaucoma. The Health Plan has denied reimbursement for the Heidelberg test on the basis it is considered experimental.There is some issue as to the clinician’s diagnosis of suspected glaucoma in this patient. The examinations from July and August of 2004 show some discrepancies in the appearance of the optic nerve, and it is questionable if the intraocular pressure was significantly elevated. Though there were asymmetric cup to disc ratios noted on the 8/2/04 exam, the optic nerves were shown to be equal on the 7/20/04 exam.

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