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

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for referrals to head and neck surgery, maxillofacial surgery, chiropractic, cardiology, pulmonology and a bone density test for evaluation of the enrollees neck pain, back pain, chest pain, and headaches. Findings: The physician reviewer found that with regard to the request for referral to head and neck surgery and referral to maxillofacial surgery, the records indicate that the patient was previously evaluated by a head and neck surgeon. This evaluation included a history, an examination, an assessment and plan. The provider did not find that the patient was a candidate for any surgical intervention and recommended treatment with corticosteroid nasal spray and salt water nasal spray. Further, the patient had subsequent imaging of the sinuses and nasal septum both with CT and MRI. The findings of these imaging studies were normal. In this case, the records indicate that the patient received a complete evaluation for her nasal and sinus symptoms by an otolaryngologist and was provided with appropriate treatment recommendations. Subsequent imaging studies were negative. As noted by the provider, there was no indication for surgical intervention. The terms head and neck surgeon and maxillofacial surgeon are interchangeable with an otolaryngologist. In summary, there is no evidence to support the request for another evaluation by a head and neck surgeon or with a maxillofacial surgeon. Thus, the requested referral to head and neck surgery and referral to maxillofacial surgery are not medically necessary for evaluation of this patients medical condition. With regard to the request for a referral to cardiology, the records indicate that the patient has already undergone an evaluation for potential cardiac causes for her ongoing symptoms of chest pain and palpitations. This has included repeated visits to her primary provider and emergency medicine providers as documented in the medical records. Further, she has had normal laboratory tests to include cardiac markers and a normal myocardial perfusion stress test with echocardiogram. These tests have effectively excluded the presence of a serious cardiac etiology for her ongoing symptoms. There has been no change in her status since these tests have been performed. In this case, the records indicate that the patient has received all of the appropriate tests that are offered by a cardiologist for her symptoms and there is no evidence provided to support the rationale for another cardiology assessment. For these reasons, a referral to a cardiologist is not medically necessary for evaluation of this patients medical condition. With regard to a referral to pulmonology, the records indicate that the patient has received an assessment for causes of episodic shortness of breath. This has included repeated assessment of vital signs to include oxygen saturation levels during episodes in which she was symptomatic. All of the recorded oxygen saturation levels were normal. Further, the patient has undergone repeated physical examinations of her lungs during exacerbation of symptoms. All of her exam findings from multiple providers were normal. Chest x-rays have been normal as well. In this case, there is no sign or symptom provided by the patient or finding from vital signs to include oxygen saturation tests or chest x-rays to suggest a pulmonary etiology for her underlying chronic symptoms. For this reason, referral to a pulmonology is not medically necessary. With regard to the requested referral for chiropractic care, there is no specific symptom or rationale provided by the patient for this request. Further, there is no specific evidence that there is an impairment in functional abilities so that progress may be measured. For these reasons, the requested chiropractic care is not medically necessary for treatment of this patients medical condition. With regard to the request for bone density testing, the U.S. Preventive Services Task Force (USPSTF) guidelines are used as a means to determine the need for bone density testing. According to the USPSTF guidelines, the medical records do not provide sufficient evidence that this patient has sufficient risk factors to warrant the use of bone density testing. The USPSTF guidelines recommend screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. Risk factors include prior fracture, family history of osteoporosis, smoking, use of glucocorticoids, rheumatoid arthritis, conditions which are associated with secondary osteoporosis, and heavy use of alcohol. Thus, the requested bone density test is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in family practice and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.