X-Ray 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 a dual-energy X-ray absorptiometry (DXA) bone density study (CPT 77085).Findings: Three out of three physician reviewers found that the services at issue were likely to have been more beneficial than any other available standard treatments for the enrollee’s medical condition.The American College of Radiology (ACR) has established Appropriateness Criteria to help guide referring practitioners in their most efficient and efficacious use of imaging for various clinical presentations. In their guidelines for osteoporosis screening or initial imaging of clinically suspected low bone mineral density (Variant 1), a DEXA scan is identified as a first line study and assigned the Appropriateness Category of “Usually Appropriate”.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an ovarian/pelvic venography with or without embolization. In this case, the records suggest a diagnosis of pelvic venous insufficiency. An ultrasound reported prominent vessels in the bilateral adnexa with PCS. Visit notes reported that computed tomography (CT) imaging showed a dilated 11 mm right ovarian vein, and two dilated left ovarian veins at 11 mm and 9 mm, compatible with reflux. Bookwalter and colleagues note that when pelvic venous congestion syndrome (PVCS) is caused by incompetent gonadal vein valves, treatment typically is performed by means of embolization via a minimally invasive catheter with excellent technical and clinical success rates.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for x-ray of the thoracic spine and magnetic resonance imaging (MRI) of the back. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the patient’s back pain. The submitted documentation does not support the medical necessity of the requested services. Evidence-based medical guidelines state that spine radiography should not be recommended in patients with low back pain in the absence of red flags for serious spinal pathology, even if the pain has persisted for at least six weeks. Guidelines recommend thoracic MRI in the setting of trauma with neurologic deficit.

Nature of Statutory Criteria/Case Summary: An enrollee has requested a computed tomography (CT) angiogram for evaluation of his medical condition. Findings: Two physician reviewers found that if coronary ischemia is suspected then some form of stress testing is considered standard of care and most appropriate accepted practice in the medical community (Hendel et al). Coronary CT angiography defines coronary anatomy only, and does not assess the functional significance of any potential stenosis identified. Moreover, Miller and colleagues found that coronary CT angiography is less accurate compared to conventional angiography and may miss small branch vessel stenosis that could be identified on stress testing which may be responsible for the patient's symptoms.

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 X-Ray, then check the rights and deadlines that apply to your plan.