Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old female enrollee requested: (1) neuro-ophthalmology referral; (2) panel for paraneoplastic antibodies including but not limited to anti-gangliocyte panel; (3) magnetic resonance imaging (MRI) of the abdomen with and without contrast; (4) MRI of the cervical spine with and without contrast; (5) MRI of the chest with and without contrast; (6) MRI of the lumbar spine with and without contrast; (7) MRI of the thoracic spine with and  without contrast; (8) XR modified barium swallow with an occupational therapist (OT) or speech language pathologist (SLP); (9) motion fluoroscopic evaluation; swallow function; cine/video recording; and (10) swallowing function with cineradiography or videography, for medical evaluation and/or treatment of the enrollees dysautonomia, postural orthostatic tachycardia syndrome (POTS) and autonomic neuropathy.  Findings:  The physician reviewer found that upon review of the submitted medical records and relevant peer-reviewed scientific literature, the requested services are not medically necessary for evaluation and/or treatment of the patients medical condition.  Based upon review of the submitted medical records, there is no documentation of pupillary dysfunction, ophthalmology or neuro-ophthalmology symptoms. As such, there are no clinical findings to support an evaluation by a neuro-ophthalmologist at this time.  The appropriateness of paraneoplastic antibody testing in this clinical setting depends upon the specific antibodies being requested. In this case, the submitted documentation does not indicate which particular antibodies are to be tested and/or the rationale to support such testing. Thus, the requested panel for paraneoplastic antibodies including but not limited to anti-gangliocyte panel is not medically necessary.  In the absence of documented clinical findings suggestive of malignancy, use of an MRI of the abdomen, cervical spine, chest, lumbar spine and thoracic spine, as a screening tool is not consistent with the standard of care in this setting. Therefore, the requested MRI of the abdomen, cervical spine, chest, thoracic spine and lumbar spine with and without contrast is not medically necessary.  In the absence of documented clinical findings suggestive of a swallowing dysfunction, XR modified barium swallow with OT or SLP as a screening tool for a swallowing dysfunction is not consistent with the standard of care in this setting. Therefore, the requested XR modified barium swallow with OT or SLP is not medically necessary.  In the absence of documented clinical findings suggestive of a swallowing dysfunction, the use of fluoroscopic evaluation of swallowing function as a screening tool for a swallowing dysfunction is not consistent with the standard of care in this setting. Therefore, the requested motion fluoroscopic evaluation; swallow function; cine/video recording is not medically necessary.  In the absence of documented clinical findings suggestive of swallowing dysfunction, the use of swallowing function evaluation with cineradiography or videography as a screening tool for a swallowing dysfunction is not consistent with the standard of care in this setting. Therefore, the requested swallowing function with cineradiography or videography is not medically necessary.