Appeal type: Medical Necessity
Decision: Overturned

The patient is a 53-year-old female who was found to have a nodular thyroid by her gynecologist and was referred for a confirmatory ultrasound. The patient consulted an endocrinologist/thyroidologist in July 2005.  She had been on lithium for nine years and apparently had a normal TSH a year prior to the visit, a low TSH in May 2005, and another subsequent TSH level that was said to be high. According to the initial office notes, the patient complained of a 30-pound weight gain and insomnia. The initial laboratory evaluation revealed normal T3 and T4 levels, a suppressed TSH level, an elevated thyroglobulin, and multiple negative thyroid antibodies. There are no notes documenting the full extent of the providers initial physical examination. An ultrasound performed that day is compatible with a small multi-nodular goiter.The following week the patient returned; the lab tests were reviewed and she was started on propranalol, 10 mg twice daily. A radioactive iodide uptake study and scan were initiated and showed no significant uptake of iodide. In August 2005 the patient returned again, and her weight, pulse and blood pressure were documented. She was apparently advised to exercise and to gradually discontinue her propranalol over a 10-day period.The patient has requested reimbursement for the office evaluations with the endocrinologist/thyroidologist and the laboratory and imaging studies.  The Health Plan denied her request based upon a determination that the services were not medically necessary.Long-term treatment with lithium can cause a goiter that may be associated with an elevated TSH and hypothyroidism in up to 50% of patients. The patient here was said to have had variously normal, elevated, and suppressed TSH concentrations in the past. Her initial office visit revealed a suppressed TSH with normal thyroid function tests. The thyroglobulin blood test is consistent with the small goiter found on the ultrasound during that visit. Repeat TSH and thyroid function tests done one month later were normal. The reason for the propanalol administration is not clear, since she apparently did not have hyperthyroid symptoms for which that medication might be prescribed. The iodide uptake study and scan, done for reasons that are not clear, showed essentially no uptake. There is not enough information to specifically determine the patients underlying thyroid problem, but it may be that she had an episode of silent subacute thyroiditis and was transiently hypothyroid. The record indicates the patient was subsequently seen by two other endocrinologists and placed on thyroxine. These records were not provided. The patients self-referral to an endocrinologist was appropriate. However, the medical justification for some of the myriad of lab tests and imaging studies is not apparent from the records that were submitted. Based on the record provided, the Health Plan should reimburse the patient for the initial office evaluation with the thyroidologist, the laboratory testing conducted in July 2005 and the thyroid ultrasound done in July 2005.   Therefore, I have determined a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.