Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 66-year-old female who has a history of melanoma of the right eye. She also had degenerative eyesight. In August 2004, a Heidelberg retinal test was performed to rule out glaucoma. The Health Plan has denied reimbursement for the Heidelberg test on the basis it is considered experimental.There is some issue as to the clinicians diagnosis of suspected glaucoma in this patient. The examinations from July and August of 2004 show some discrepancies in the appearance of the optic nerve, and it is questionable if the intraocular pressure was significantly elevated. Though there were asymmetric cup to disc ratios noted on the 8/2/04 exam, the optic nerves were shown to be equal on the 7/20/04 exam. While the Heidelberg retinal test is an appropriate test for documenting the appearance of optic nerve head in glaucoma suspects, the submitted documentation does not demonstrate the test was clinically indicated in this case. Therefore, I have determined that the test at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 66-year-old woman who apparently after one visit with her ophthalmologist underwent a visual field test and Heidelberg retinal test because of suspicions of glaucoma. The eye pressure was within a normal range, though asymmetric, and there was no indication of examination of the nerve. The patient has requested reimbursement for the Heidelberg retinal test. The Health Plan has denied the request indicating the test at issue is considered investigational.Review of the submitted clinical evidence demonstrates no indication of examination of the optical nerve, a critical factor in evaluating for glaucoma. The patient had not had a dilated retinal/optic disc exam and the visual field test had not yet been followed sequentially or repeated due to low reliability. Furthermore, the Heidelberg retinal test was ordered prior to having more than one pressure reading, and the one pressure reading was not high. As such, there was no indication for performance of a Heidelberg retinal test in this clinical setting. Therefore, I have determined that the test at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 66-year-old female with a diagnosis of suspected glaucoma. Notes from an office visit in August 2004 shows intraocular pressure of 18 mm Hg in both eyes. There was slight asymmetry of the optic cups, but the dimensions are not generally considered glaucomatous. Visual field plots were essentially normal. It appears the patient was not taking any glaucoma medications. Visual acuity was normal. A Heidelberg retinal test was ordered by the patients provider and the patient is requesting reimbursement for the test.Based on the clinical information provided, suspicion of glaucoma in this case was very low. The Heidelberg retinal test provided no helpful information regarding management of the patient. Given the benign nature of the patients ocular status, it would be extremely unlikely that the confocal scan would add to the decision making process in any meaningful way. Conventional examination techniques would have been more than adequate in this case. Therefore, I have determined that the test at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.