Req 2nd Opin OON denials: what the review data shows

Where the denial was overturned

The patient is a 25-year-old man diagnosed in September 2005 with metastatic desmoplastic small round blue cell tumor. His disease was primarily intra-abdominal/pelvic, though a supraclavicular lymph node biopsy revealed metastatic disease. He was seen and evaluated by a medical oncologist and received six cycles of chemotherapy of alternating CAV and IE. Repeated radiologic imaging demonstrated a partial response, with residual pelvic disease encasing and obstructing the ureter causing hydronephrosis.The patient was seen by an in-plan surgical oncologist in April 2006 who did not recommend surgery, stating that it would only determine whether there was residual viable cancer and that surgical excision of residual disease would not improve survival or provide a cure. He recommended observation with repeat radiologic imaging, and resumption of chemotherapy if the tumor progressed.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for treatment with an anatomic and clinical pathologist. Findings: The physician reviewer found that there is support in the medical literature for the requested services in this clinical setting. Cysts or tumors of the jaws may present in a variety of ways. One way tumors are identified is through persistent pain. Another method is through radiographic evidence. The patient has been treated by several providers, has had surgery and yet, she still experiences jaw pain. This patient has well documented pain and radiographic evidence demonstrating possible progression of the lesion. The patient was treated with several therapies without resolution. It is medically reasonable and necessary to be certain a tumor of the jaw is not present, in this patient’s case.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for second neuropsychological examination. This patient was administered a battery of neurocognitive tests to evaluate cognition, memory, attention, and concentration. All of the tests administered to the patient are widely used and are considered to be valid and reliable measures of their focus. The tests have also been demonstrated to yield consistent results when administered by different providers. This patient’s personality profile, according to the Minnesota Multiphasic Personality Inventory (MMPI), indicates an unusually high number of symptoms endorsed in the areas of somatic, psychiatric, and cognitive functioning. This result suggests that the patient may be overly focused on these issues, which may further compound his distress and lead to further impairment.

The patient has requested authorization and coverage for applied behavior analysis (ABA) services of 60 hours per week at 2:1 ratio, 10 hours per month of mid-level supervision, and 120 hours per month of high-level supervision, in the alternative ABA services of 60 hours per week at a 2:1 ratio, 38 hours per month of mid-level supervision, and 12 hours per month of high-level supervision. The Behavior Analyst Certification Board (BACB) outlines that, “many variables, including the number, complexity, and intensity of behavioral targets and the client’s own response to treatment help determine which model is most appropriate.” A targeted assessment and treatment in a center-based model, by providers specifically trained to treat challenging behavior, is preferable to in-home ABA services.

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 Req 2nd Opin OONwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.