Ultrasound denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the office visit and related services required on an emergent or urgent basis. Findings: The physician reviewer found that the patient presented with a concern for a recurrence of testicular cancer. The physical examination did not demonstrate a palpable mass. Moreover, an ultrasound is not indicated in the setting of a negative physical examination. Based on the patient’s presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition that was likely to place the patient’s health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care.

Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested reimbursement and prospective authorization and coverage for ultrasound, sclerotherapy and anesthesia performed for treatment of the enrollee who has a history of varicose veins and Klippel-Trenaunay syndrome. Findings: The physician reviewer found that there is sufficient support in the documentation provided for the services at issue in this clinical setting. This patient has been diagnosed with KTS and it is considered standard to treat lesions that are painful and localized for adequate venous drainage. KTS is a relatively rare condition, and there are limited universal treatment guidelines. However, there is sufficient medical literature to support the use of sclerotherapy for treatment of lesions associated with KTS.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for ablation therapy, bilateral sclerotherapy, and ultrasounds. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s varicose veins.Findings: The documentation provided does not support the requested services in this clinical setting. The records do not show that this patient has had resolution of his peripheral artery disease issues. On the left side, it is documented that the pedal pulses are no longer palpable. There is no documentation of palpable pedal pulses on the right at the most recent visit. The records provided do not include formal Doppler pressure study such as an ankle brachial index (ABI).

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for soft tissue mobilization, phonophoresis with dexamethasone cream, ultrasound, iontophoresis, electric stimulation, traction and therapeutic massage. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s hip impingement and mild scoliosis.Findings: The submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting. The proposed interventions do not address the patient’s underlying condition. Femoroacetabular impingement is a poorly understood condition, overall, with limited high grade evidence in the extant literature to inform optimal management outside of surgery to address pathological anatomy. (Amanatullah et al; Freke et al; and Mansell et al).

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