Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for (1) ophthalmology referral and (2) any or all the requested following ophthalmology services/tests: ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; new patient office or other outpatient services; special ophthalmological services and procedures; visual field examination, unilateral or bilateral, with interpretation and report; special anterior segment photography with interpretation and report; scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report; ophthalmic ultrasound, diagnostic; other specialized ophthalmological services and procedures; ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; established patient office or other outpatient services. The submitted documentation supports the medical necessity of a portion of the requested services. Changes to the scleral color or thickness may be an indication of a systemic disease. While changes such as calcific senile plaques are common in older patients, they are not common in younger patients. Given this patients age, evaluation by an ophthalmologist is medically indicated. Therefore, an (1) ophthalmology referral is medically necessary for the evaluation of this patient. In this case, while ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program is medically indicated, new patient office or other outpatient services may not be billed when the code for ophthalmological services is being used. As there are no corneal findings, special ophthalmological services and procedures are not medically indicated. Given that there is no suspicion of any visual field change documented in this case, visual field examination, unilateral or bilateral, with interpretation and report, is not medically indicated. In this case, given that the services, testing, and imaging that are relevant for evaluation of the patient may include anterior segment optical coherence tomography, which is used to evaluate scleral thickness in the areas of discoloration, special anterior segment photography with interpretation and report and scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report are medically indicated. As there are no suspected problems in the back of the eye, ophthalmic ultrasound, diagnostic is not medically indicated. As there are no lid or adnexal changes, other specialized ophthalmological services and procedures are not medically indicated. As the patient is a new patient, the following services for established patients are not medically indicated: ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; established patient office or other outpatient services. Therefore, (2) the following ophthalmology services/tests: ophthalmological services, special anterior segment photography with interpretation and report, and scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report are medically necessary for the evaluation of this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.