Organ Transplant denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 59-year-old male who has end-stage COPD requiring continuous supplemental oxygen. He is receiving long-term treatment with steroids and frequent treatment with oral antibiotics. The patient is also Hepatitis C positive. The record indicates the patient has been evaluated for a single lung transplant at two transplant centers and both determined he was not a candidate due to his Hepatitis C status. The patient then consulted with the Cleveland Clinic, which apparently has accepted him as a single lung transplant candidate. This is a patient with end stage lung disease who also has hepatitis C. At issue is whether the patient is a candidate for a lung transplant. Three reasons were stated as to why the patient may not be a candidate despite meeting all other criteria to be listed as a candidate. The prime reason is the presence of Hepatitis C in the patient.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for immediate referral for a liver transplant. Early liver transplant in the setting of decompensated alcoholic liver disease, defined as before six months of abstinence from alcohol, is recommended for carefully selected patients with severe medically refractory alcohol associated liver disease who are considered to be at low risk for alcohol relapse post-transplant (Crabb, et al.). Weinberg and colleagues reported that early liver transplantation has been successfully performed in patients with severe alcohol associated hepatitis and prior liver decompensation. This patient presents with a history of alcohol use disorder, alcohol withdrawal seizures, chronic pancreatitis, and alcohol-associated hepatitis.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for platelet rich plasma. In gynecology, the research on platelet rich plasma therapy is very limited and primarily anecdotal. A recent publication presents a comprehensive review of the use of platelet rich plasma in various gynecologic applications including treatment for refractory endometrium, Asherman's syndrome, poor ovarian response, wound healing, lichen sclerosus, female sexuality issues, vesicovaginal fistula, stress urinary incontinence, and bladder pain syndrome. While the authors acknowledge the potential of platelet rich plasma for these applications, they highlight the need for further studies to confirm its effectiveness and explore its application in other disorders.

The patient is a 68-year-old man with a history of renal failure due to obstructive uropathy, which is likely due to a history of a long-standing enlarged prostate. He wishes to have a kidney transplant. The transplant team recommends he have urologic evaluation, and possible transurethral resection of the prostate (TURP) to decrease the risk of obstructive uropathy effect on the possible kidney transplant. The patient notes he has seen urologists in the past who have recommended he have a TURP procedure, but he has always refused. The patient believes his kidney failure is due to salt overload and he is attempting exercises to help his prostate. The patient does not wish to undergo a TURP procedure as recommended by his provider. He wishes to be listed for kidney transplant without urologic clearance.

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 Organ Transplant, then check the rights and deadlines that apply to your plan.