Vision Services 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 corneal collagen cross-linking procedure, on the left eye and prospective authorization and coverage, procedure code 0402T, on the right eye. The Health Plan has denied this request indicating that the procedures at issue were and are considered investigational for treatment of the enrollee’s keratoconus.Findings: There is support in the medical literature for the efficacy of the corneal crosslinking in this patient’s case. Cross-linking is a U.S. Food and Drug Administration (FDA) approved procedure for keratoconus and post refractive ectasia. The FDA approved this procedure in 2016. The primary purpose of crosslinking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking procedure for treatment of the enrollee’s bilateral keratoconus. Findings: The 3 physician reviewers found that there is support in the medical literature for the superior efficacy of the services at issue in this patient’s case. Based on the patient’s vision loss and previous treatment with glasses and contacts, the cross-linking was the most appropriate and effective treatment available. There is a large body of available literature in support of corneal collagen cross-linking for treatment of this patient. The evidence shows corneal collagen cross-linking as a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full thickness corneal transplant.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for vision therapy, as well as, authorization and coverage for future vision therapy services. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollee’s convergence insufficiency. A review of the record indicates that the enrollee has been diagnosed with, marked convergence insufficiency, binocular dysfunction and headaches. A visit note indicated the enrollee had occasional headaches, difficulty with sustaining near point work, and occasionally saw double. The provider noted spectacle lenses were recommended for near work and recommended weekly in-office neuro-optometric therapy sessions with periodic progress evaluations.The submitted documentation fails to demonstrate the medical necessity of the service at issue.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for continued orthoptic training for treatment of her binocular vision disorder. Findings: The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting. The goal of orthoptic therapy is to stimulate and normalize accommodative, oculomotor and vergence abilities. The endpoint of orthoptic therapy for these conditions is when the patient is able to maintain clear, single binocular vision with a series of orthoptic tasks. Eye conditions such as convergence insufficiency, accommodative insufficiency, and ocular motor dysfunction are successfully treated with orthoptic therapy.

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