Radiofrequency Ablation denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 38-year-old woman with bilateral symptomatic venous disease due to greater saphenous vein incompetency. The patient has requested authorization for radiofrequency ablation, which has been denied by the Health Plan on the basis that it is considered investigational in nature.There is now sufficient peer-reviewed, randomized, controlled clinical trials with medium and long-term follow-up to support the use of radiofrequency ablation closure in the treatment of greater saphenous vein incompetence of symptomatic varicose veins. It is as effective as standard surgical therapy and is associated with significantly less rehabilitation and long-term morbidity. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

Gender: FNature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for radiofrequency ablation (RFA), aquatic physical therapy, electromyography, and/or magnetic resonance elastography. On review of the available records, the requested aquatic physical therapy is medically necessary for this patient’s treatment. A recent randomized controlled clinical trial concluded that aquatic exercise programs led to greater alleviation in patients with chronic low back pain than physical therapy modalities and had a long-term effect up to 12 months. Similarly, another study randomized patients to aquatic therapy and traditional therapy and found that the aquatic group showed significant clinical improvement in pain, disability, and quality of life.

Where the denial was upheld

Physician #1: The patient is a 54-year-old male who presented with rectal bleeding in May 2004. He was found to have a 5.0cm circumferential rectal cancer. The CT scan showed a 3.5cm lesion in the liver which was positive on PET scan leading to a diagnosis of stage IV adenocarcinoma of the rectum. He was treated with chemotherapy (FOLFOX plus Avastin) and had a resection of his rectal carcinoma. There was a second operation with resection of his liver metastases and a second round of chemotherapy (FOLFOX) and radiation. A CT scan in July 2005 showed a mass in the right lung. A repeat CT scan and a PET scan showed three nodules in the right lung and one nodule in the left lung. In October 2005 the patient underwent right lower lobectomy and resection of the right middle lobe nodule. The pathology report showed metastatic adenocarcinoma in each specimen.

Physician 1The patient is a 59-year-old man who had lung surgery in August 2002. At that time he had resection of his right lower lobe, revealing a poorly differentiated squamous cell cancer, 3cm in size, with negative nodes. In March 2003, the patient developed two areas of endobronchial recurrence. He then underwent chemotherapy with little response. An endobronchial biopsy in June 2003 again was positive. The patient was treated with external beam radiation therapy from June 2003 to July 2003. Repeat bronchoscopy in September 2003 showed persistence of one of the lesions and the patient was treated with local brachytherapy to this lesion.In December 2003, CT scan of the chest demonstrated two new pulmonary nodules, each about 1cm in size. One was at the right lung base and the other was in the superior segment of the right lower lobe.

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 Radiofrequency Ablation, then check the rights and deadlines that apply to your plan.