Prev Health Screen denials in California external review

What the reviewers wrote

Where the denial was overturned

An enrollee has requested authorization and coverage for the Gardasil 9 vaccine series. Updated recommendations of the CDC Advisory Committee on Immunization Practices (ACIP) for vaccination against human papillomavirus (HPV) note that the public health benefit of HPV vaccination in all adults greater than 26 years of age is minimal, but that shared clinical decision-making regarding HPV vaccination is recommended for some adults aged 27 to 45 years, because some persons who are not adequately vaccinated might benefit. In this case, the patient is within the 27 through 45 years age range identified by the ACIP. Furthermore, the updated recommendations of the ACIP state that shared decision-making regarding HPV vaccination is recommended for this population.

Nature of Statutory Criteria/Case Summary: An enrollee requested a one-on-one visit with a nutrition specialist for medical treatment of her diabetes. Findings: The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. This patient has a high BMI and has type 2 diabetes mellitus. Lifestyle interventions and medical nutritional therapy are essential cornerstones of diabetes management. It is standard of care that obese patients with diabetes be referred to individualized medical nutritional therapy as part of diabetes self-management education, especially if they have been unsuccessful in losing weight. A patient with morbid obesity requires individualized medical nutritional therapy. A weight loss of 5% or greater may have significant effect in the outcomes and improvement of diabetes and blood pressure control.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing for cancer screenings for evaluation of the enrollee, who has a family history of multiple high risk cancers. Findings: The 3 physician reviewers found that the patient is a 51-year old female with type II diabetes, hypertension, and dyslipidemia. She was noted to have a family history of cancer. However, the patient’s mammogram was negative and a Pap smear was also negative. The patient underwent genetic testing. The patient requested reimbursement for genetic testing. The results showed a variant of uncertain clinical significance. The Health Plan denied reimbursement noting that the services at issue were investigational for the evaluation of this patient. This patient’s history is not suggestive of hereditary predisposition to cancer.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Prometheus Anser IFX diagnostic testing for evaluation of the enrollee’s ulcerative colitis. Findings: The physician reviewer found that In this case, Prometheus Anser IFX diagnostic testing was ordered to determine Remicade level, and whether antibodies to Remicade were present. However, loss of response to Remicade can occur for many reasons. The presence of antibodies alone does not necessarily result in loss of response to infliximab or infusion reactions, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.

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 prev health screen, then check the rights and deadlines that apply to your plan.