Referral Out Of MG denials: what the review data shows

Where the denial was overturned

A parent of an eight-year-old female enrollee has requested repeated esophageal dilation procedures within her local community, rather than at a facility that is approximately 130 miles/3 hours from her residence for treatment of the enrollee’s recessive dystrophic epidermolysis bullosa and recurrent esophageal stricture. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services. Epidermolysis bullosa represents a collection of disorders characterized by development of blisters with trauma and worsening in warm weather. This patient suffers from the recessive dystrophic type, involving severe blistering and scarring, including involvement of the gastrointestinal tract and urologic system.

A 46-year-old female enrollee has requested a board certified gynecologic oncologist to perform the requested services (including risk reducing salpingo-oophorectomy and specialized pathology examination of the specimens) for treatment of her BRCA2 positive. Findings: The physician reviewer found that The American College of Obstetricians and Gynecologists (ACOG) indicates that the surgical procedures for risk reduction include complete removal of the ovary and fallopian tube, pelvic washings, and thorough assessment of the peritoneal cavity with biopsies as indicated. Some patients will have an occult malignancy identified at thorough surgical sectioning of these ovaries and fallopian tubes. Overall, ACOG does not specify what type of provider should perform this type of surgery.

Where the denial was upheld

A 46-year-old female enrollee has requested acute psychiatric inpatient services for treatment of her depression and eating disorder. Findings: The physician reviewer found that considering the robust affective, psychodynamic and characterological aspects of this patient’s condition, selection of the appropriate level of care and length of stay is challenging. Clinical guidelines and patient placement criteria have been developed to assist with such complicated determinations, and it is the task of the providers working directly with the patient to interpret and apply these tools. In this patient’s case, the documentation provided does not describe an acute psychiatric syndrome, significant disability, or medical illness that would necessitate services at the acute level of care.

A 24-year-old female enrollee has requested authorization and coverage for a chiropractor referral for treatment of the enrollee’s upper back pain. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested service in this patient’s case. No clinically significant benefit with respect to analgesic, health, or functional outcomes is expected with a referral to a chiropractor in this clinical setting. There is a lack of proven benefit of chiropractic treatment in the setting of chronic spinal pain or other musculoskeletal conditions. Ernst and colleagues conducted a review of prior systematic reviews and concluded that rigorous clinical trials have not demonstrated that chiropractic care and massage are effective interventions for pain control.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Referral Out Of MGwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.