Vision Services/Ophthalmology denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee requested reimbursement for placement of an amniotic membrane graft on the right cornea for a history of penetrating keratoplasty graft in the right eye that developed a corneal ulceration. He also requested authorization and coverage for future placement of a second amniotic membrane graft on the right cornea, if necessary. His ophthalmologist recommended a self-retained amniotic graft when his epithelial recovery appeared stalled. He underwent a right central cornea amniotic membrane transplant. This amniotic membrane was used to promote healing of a non-healing central corneal ulcer; non-infectious. The operative note indicated he had not responded to conservative medical management and typical treatment. During a follow up visit, the epithelium was noted to be substantially improved but not yet closed.

Nature of Statutory Criteria/ Case Summary: The enrollee requested coverage for Ex-Press Glaucoma Filtration Device, Hydrus Microstent, or iStent Trabecular or Inject Trabecular Micro-Bypass Stent. The health plan has denied this test as experimental/investigational. According to the medical record, the patient was diagnosed with glaucoma, cataracts, macular degeneration, bilateral retinal hemorrhage, ocular hypertension, hypertension, atrial fibrillation, and diabetes mellitus. He has been using eye drops including BromSite, Durezol, and Combigan for intraocular pressure. The clinical note indicates the patient presented for cataract evaluation to the right eye. The patient stated that the vision in the right eye had been getting worse for six months at all distances with a lot of glare at night and with bright sun. Both eyes were dry.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent requested authorization and coverage for vision therapy. The enrollee has refractive amblyopia of the left eye and suppression of binocular vision. He has been wearing glasses for about two years. His eye exam noted 20/40 vision in the left eye. The record indicates the enrollee’s right eye is patched four hours per day. The recommendation was for this process to continue. The enrollee’s mother was told a trial vision therapy could be done to work on bilateral integration, spatial awareness, eye-hand coordination, primitive reflex integration, and the development of gross motor/foundation movement. A progress note indicated the vision therapy was going well and the therapy should be continued. The medical record indicates the enrollee’s comprehensive testing revealed a primary diagnosis of Amblyopia of eye (H53.009).

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent requested authorization and coverage for optometric vision therapy. The enrollee has refractive amblyopia in both eyes. She has anterior visual midline shift syndrome (VMSS) and requires yoked prism in her lenses to center the VMSS. These lenses are a form of vision therapy and will change as her visual system improves and becomes more integrated. The optometrist has recommended neuro-optometric vision therapy, designed to increase the visual sub skills necessary for proper educational intervention.

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