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The patient is a five-year-old female with a medical history significant for torticollis. The patients parent has requested reimbursement for one-day stay (CPT code 99221) in the pediatric intensive care unit on 5/16/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient.
In this patients case, she presented with stable hemoglobin, indicative of no ongoing blood loss. | Upheld | Medical Necessity | Summary Reviewer
The patient is a five-year-old female with a medical history significant for torticollis. The patients parent has requested reimbursement for one-day stay (CPT code 99221) in the pediatric intensive care unit on 5/16/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that blunt abdominal trauma is the third most common cause of pediatric deaths, generally affecting the liver and spleen. Contusions, lacerations, and hematomas are the most likely injuries. Duodenal and pancreatic injuries are not unusual following direct blows to the abdomen or trauma involving bicycle handlebars. Children are at greater risk of renal injuries because of weaker abdominal musculature, decreased perirenal fat, and more flexible thoracic cage. A careful history and physical examination are essential, and when combined with the mechanism of injury, should provide guidance in diagnostic work-up and disposition. However, physical findings can be misleading, and repeated examinations may be necessary to determine need for further diagnostic investigation. Additional information can be gleaned from abdominal ultrasound, with abdominal CT reserved for more symptomatic patients (due to the radiation exposure). Specifically regarding renal trauma, organ preservation is of highest priority. Renal injuries are graded from I to V, with IV and V considered to be high grade and I and II to be low grade. Grade III represents a moderate injury. The trend in management is toward non-operative management, with short- and long-term monitoring for hypertension and persistent bleeding. In this patients case, she presented with stable hemoglobin, indicative of no ongoing blood loss. While it was reasonable to monitor her with serial examinations and laboratory evaluations, she was overall hemodynamically stable, with no evidence of impending circulatory collapse. She did not require acute inpatient admission and could have been safely managed at a lower level of care. Therefore, one-day stay (CPT code 99221) in the pediatric intensive care unit on 5/16/20 was not medically necessary for the treatment of this patient. | 1 |
A 60-year-old female enrollee has requested authorization and coverage for Euflexxa injections. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition.
In this case, the patient has been diagnosed with osteoarthritis of the left knee. She presents with worsening left knee pain and functional mobility impairments. Clinical examination findings are consistent with radiographic evidence of tricompartmental osteoarthritis. She underwent a series of Euflexxa injections in May 2018 and June 2018, with significant pain reduction and improvement in her mobility that lasted six months. She has failed to achieve adequate relief with prior corticosteroid injection, nonsteroidal anti-inflammatory drugs, activity modification, physical therapy, and home exercise program. | Overturned | Medical Necessity | Summary Reviewer
A 60-year-old female enrollee has requested authorization and coverage for Euflexxa injections. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. If there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to perform another series. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat injections of viscosupplementation have been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient has been diagnosed with osteoarthritis of the left knee. She presents with worsening left knee pain and functional mobility impairments. Clinical examination findings are consistent with radiographic evidence of tricompartmental osteoarthritis. She underwent a series of Euflexxa injections in May 2018 and June 2018, with significant pain reduction and improvement in her mobility that lasted six months. She has failed to achieve adequate relief with prior corticosteroid injection, nonsteroidal anti-inflammatory drugs, activity modification, physical therapy, and home exercise program. Therefore, the requested Euflexxa injections are medically necessary for the treatment of this patient. | 1 |
A 57-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/01/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. | Overturned | Experimental | Summary Reviewer 3
A 57-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/01/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this patients case, her breasts were described as heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast tomosynthesis performed on 9/01/16 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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A 24-year-old male enrollee has requested reimbursement and prospective authorization and coverage for substance use intensive outpatient services provided from 10/02/18 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health conditions. | Overturned | Medical Necessity | Summary Reviewer
A 24-year-old male enrollee has requested reimbursement and prospective authorization and coverage for substance use intensive outpatient services provided from 10/02/18 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. With regards to risk of harm, the records support a score of 2 due to recent suicidal ideation. In terms of functional status, the records support a score of 2 due to quitting a recent job and conflict with peers. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability with some mental health issues that appear under good control. In terms of level of stress of the recovery environment, the records support a score of 3 due to a stable living environment but conflict with peers there. With regards to level of support of the recovery environment, the records support a score of 3 due to mention in the records of sober living with few supports. In terms of treatment and recovery history, the records support a score of 3 due to fair recent treatment response in the intensive outpatient program. With regards to engagement and recovery status, the records support a score of 2 due to good cooperation in treatment. Thus, the patient has a composite sore of 17. This score correlates with intensive outpatient program level of care. All told, substance use intensive outpatient services provided from 10/02/18 forward were and are medically necessary for the treatment of this patient. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. | 0 |
A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. | Overturned | Experimental | Summary Reviewer 2
A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. The physician reviewer found that in this circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting an increased bleeding risk or percutaneous left atrial appendage exclusion using a Watchman device. The U.S. Food and Drug Administration (FDA) has approved the Watchman device. The Watchman device is an appropriate alternative in patients who are deemed to be at prohibitively high bleeding risk while on long-term anticoagulation, such as is documented with this patient. The requested services are likely to be more beneficial than the alternative of long-term anticoagulation in this patient with a documented high risk of recurrent bleeding. In sum, the requested percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device) is likely to be more efficacious than other available treatment options. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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An 18-year-old male has requested authorization and coverage for Qbrexza. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition.
. The patient has already tried and failed Drysol, a commonly used first-line antiperspirant. His provider has recommended that the patient continue to use | Overturned | Medical Necessity | Summary Reviewer
An 18-year-old male has requested authorization and coverage for Qbrexza. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that according to a recent review published in the American Academy of Dermatology, first-line treatment for primary axially hyperhidrosis is topical antiperspirants. The patient has already tried and failed Drysol, a commonly used first-line antiperspirant. His provider has recommended that the patient continue to use Qbrexa, which is also a topical antiperspirant and is U.S. Food and Drug Administration (FDA) approved for use in axillary hyperhidrosis. Additionally, the International Hyperhidrosis Society considers Qbrexa as first-line treatment for axillary hyperhidrosis. There is sufficient support for the requested medication in this clinical setting. Therefore, Qbrexa is medically necessary for the treatment of this patient. | 1 |
A 19-year-old female enrollee has requested reimbursement for residential treatment provided from 6/19/18 through 8/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions.
The patient had serious functional impairment, due to serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others as well as sporadic school attendance and declining grades.
The patient had a moderately stressful environment, due to conflict with parents and difficulty fulfilling expected roles at school and home. | Overturned | Medical Necessity | Summary Reviewer
A 19-year-old female enrollee has requested reimbursement for residential treatment provided from 6/19/18 through 8/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In terms of risk of harm, the records support a score of 4. There was serious risk of harm due to significant impulsivity with poor judgment and insight, manifested by taking cars and driving them without a license or permit, physical aggression towards parents, self-harm, as well as past suicidal ideation. With regard to functional status, the records support a score of 4. The patient had serious functional impairment, due to serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others as well as sporadic school attendance and declining grades. In terms of comorbidity, the records support a score of 3. The patient had multiple mental health concerns. With regard to level of environmental stress, the records support a score of 3. The patient had a moderately stressful environment, due to conflict with parents and difficulty fulfilling expected roles at school and home. In terms of environmental support, the records support a score of 2 due to her parents efforts to arrange and engage with outpatient and then wilderness treatment. With regard to resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment. In terms of treatment acceptance and engagement, the records support a score of 3. The patient was incompletely engaged, due to her initial difficulties accepting responsibility for her role in family conflicts. Therefore, the patient had a composite score of 23. Per CALOCUS, the recommended level of treatment in this case is medically monitored residence-based services. Furthermore, the patient meets criteria for intermediate stay medically monitored residential programs, due to history of impulsivity. Per CALOCUS, at this level of care, the length of stay usually does not exceed 60 days. In this case, the documentation does not support extending the length of stay past the usual 60-day period. The patient not meet criteria for level 5C: long-term medically monitored residence-based services. Therefore, the first two months of wilderness program services, from 6/19/18 through 8/18/18, were medically necessary for treatment of the patients condition. Wilderness program services after that date were not medically necessary. Therefore, that residential treatment provided from 6/19/18 through 8/18/18 was medically necessary for the treatment of this patient. | 1 |
A 50-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 2
A 50-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. All told, DecisionDx-Melanoma testing performed on 8/03/18 was not likely to have been more beneficial than other methods of evaluating this patient.
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patient is a 21-year-old male without a significant past medical history who presented to the
emergency department with complaints of severe abdominal pain and diarrhea. The patient has
requested reimbursement for inpatient admission at California Hospital Medical Center Los
Angeles from 6/26/21 through 6/28/21.
In this case, the patients symptoms had improved after treatment in the emergency
department. He was hemodynamically stable at the time of admission and did not require any
urgent procedures. The patient was admitted in stable condition and could have been treated at
a lower level of care. | Upheld | Medical Necessity | Summary Reviewer
The patient is a 21-year-old male without a significant past medical history who presented to the
emergency department with complaints of severe abdominal pain and diarrhea. The patient has
requested reimbursement for inpatient admission at California Hospital Medical Center Los
Angeles from 6/26/21 through 6/28/21. The physician reviewer found that the submitted
documentation fails to demonstrate the medical necessity of the services at issue. Inpatient care
is necessary when the patients signs, symptoms, and general medical condition can only be
managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an
inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient
setting. In this case, the patients symptoms had improved after treatment in the emergency
department. He was hemodynamically stable at the time of admission and did not require any
urgent procedures. The patient was admitted in stable condition and could have been treated at
a lower level of care. Therefore, inpatient admission at California Hospital Medical Center Los
Angeles from 6/26/21 through 6/28/21 was not medically necessary for the treatment of this
patient.
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A 65-year-old male enrollee has requested reimbursement for genetic testing performed on 4/16/15. The Health Insurer has denied this request indicating that the testing at issue was investigational for the evaluation of the enrollees medical condition. | Overturned | Experimental | Summary Reviewer 1
A 65-year-old male enrollee has requested reimbursement for genetic testing performed on 4/16/15. The Health Insurer has denied this request indicating that the testing at issue was investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard. The purpose of HLA-B5701 testing is to determine whether a person is likely to have an allergic reaction to abacavir. Abacavir (Ziagen) is found in several different combination regimens to treat HIV including Epzicom, Trizivir and the popular single tablet regimen Triumeq. HLA-B5701 testing is strongly recommended in most treatment guidelines prior to starting abacavir or an abacavir containing regimen. This patient is highly treatment experienced and is likely to harbor resistance to several classes of HIV medications. It is likely that he may require an abacavir-containing regimen. It will certainly be part of the consideration any time this patient will be changing medications for any reason including simplification, resistance, avoiding nephrotoxicity or bone mineral density decreases. Most HIV providers order HLA-B5701 testing, as part of the initial evaluation of an HIV patient and prefer to have the results on all patients with HIV prior to the time when abacavir is required. Waiting until abacavir is needed prior to sending the test causes delay in treatment in some cases and requires patients to return for additional office visits and blood draws. The amount of delay may vary widely based on the availability of the testing and ability for patients to access the clinic. While some providers and patients are able to accommodate this, for others it constitutes an unacceptable delay in treatment and undue burden on the patient. These burdens can be severe if testing is not readily available or patients live far from their clinic, have transportation or other access issues. For this reason, several highly regarded HIV guidelines (Clumeck, et al) recommend that HLA-B5701 be tested on all patients initially rather than wait for abacavir use. It is a test needed only once in the lifetime of the patient. Therefore, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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A 64-year-old female enrollee has requested reimbursement for Botox injections received on 10/9/14 and 10/29/15. The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition.
. In this case, the patient received Botox injections to her pectoralis muscles on two occasions following breast reconstructive surgery. | Upheld | Experimental | Summary Reviewer 2
A 64-year-old female enrollee has requested reimbursement for Botox injections received on 10/9/14 and 10/29/15. The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found Botox injections received on 10/9/14 and 10/29/15 were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient received Botox injections to her pectoralis muscles on two occasions following breast reconstructive surgery. However, there is a lack of support in the peer reviewed medical literature that Botox injections in the pectoralis muscle post expander breast reconstruction are of proven value. Winocour and colleagues performed a literature review to determine the efficacy of Botulinum toxin A (BTX-A) injections for pain relief following placement of subpectoral tissue expanders and breast implants. They concluded that there is a paucity of high-quality published trials assessing the efficacy and safety of BTX-A in relieving post-operative pain associated with sub-pectoral placement of tissue expanders and breast implantsFurther properly conducted and reported randomized trials providing high-level evidence assessing the efficacy and safety of this practice are required. In addition, Lo and Aycock reported on a prospective, randomized, double-blinded controlled trial in 23 patients to evaluate the effects of intraoperative injection of 100 U of botulinum toxin into the pectoralis muscle on one side versus placebo on the contralateral side during immediate tissue expander reconstruction after bilateral mastectomy. The authors found that there was no statistically significant difference between preoperative to postoperative changes in the pain scores on the botulinum toxin side compared to the control side at any time point postoperatively. The authors concluded that Intraoperative injection of the pectoralis muscle with botulinum toxin is not an effective method to improve pain control in tissue expander reconstruction. All told, there is a lack of evidence in the peer-reviewed literature supporting the services at issue as likely to be more beneficial for treatment of the patients condition than any available standard therapy. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. | Upheld | Experimental | Summary Reviewer 2
A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found the current medical evidence has not established the superior efficacy of the services at issue. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, while there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement. It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. All told, Anser IFX testing performed on 8/17/15 was not likely to be more efficacious than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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The parent of a four-year-old male enrollee has requested reimbursement for chromosomal microarray testing provided on 11/12/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. | Overturned | Experimental | Summary Reviewer 1
The parent of a four-year-old male enrollee has requested reimbursement for chromosomal microarray testing provided on 11/12/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the clinical utility of chromosomal microarray (CMA) is well-established, and is now considered first-line genetic testing for individuals with developmental delays and autism spectrum disorders. It is important to note that CMA technology has been shown to provide clinically actionable information. Research continues to support the use of CMA testing in the evaluation of developmental delays and autism spectrum disorders. Recent evidence-based international guidelines promote the use of CMA as a first-tier investigation for global developmental delay if no etiological indicators from history and examination are found. The higher sensitivity that it has for identifying submicroscopic deletions and duplications (than standard karyotyping methods) and better definition of the breakpoints and size of imbalances all make CMA a suitable first-line test. Therefore, chromosomal microarray testing provided on 11/12/18 was likely to have been more beneficial than other methods of evaluating this patient.
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The patient is a 27-year-old male who presented with complaints of difficulty concentrating. The patient was referred to the neuropsychology service on 9/6/17 by his primary care provider. The patient has requested reimbursement for neuropsychological testing provided from 9/20/17 through 10/4/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary.
inattention. The patients siblings were reportedly diagnosed with attention deficit hyperactivity disorder (ADHD). | Upheld | Medical Necessity | Summary Reviewer
The patient is a 27-year-old male who presented with complaints of difficulty concentrating. The patient was referred to the neuropsychology service on 9/6/17 by his primary care provider. The patient has requested reimbursement for neuropsychological testing provided from 9/20/17 through 10/4/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. From the clinical perspective, according to the American Academy of Clinical Neuropsychology, the decision to order neuropsychological testing for an individual patient remains a matter of clinical judgment. However, the medical records do not include objective observations such as a mental status evaluation, physical examination or validated rating scales like the Folstein Mini-Mental State Examination or Montreal Cognitive Assessment. There was no report of learning disorder, neurological disease, abrupt personality change, bizarre behavior or memory decline. It does not appear that the patient had engaged in treatment or lifestyle modification to address the inattention. The patients siblings were reportedly diagnosed with attention deficit hyperactivity disorder (ADHD). However, neuropsychological testing is not needed to establish the diagnosis of ADHD. Thus, the neuropsychological testing provided from 9/20/17 through 10/4/17 was not medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
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A 47-year-old male enrollee has requested reimbursement for the Oncotype Dx Colon Cancer Assay provided on 2/14/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectosigmoid cancer. | Upheld | Experimental | Summary Reviewer 1
A 47-year-old male enrollee has requested reimbursement for the Oncotype Dx Colon Cancer Assay provided on 2/14/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectosigmoid cancer. The physician reviewer found that in the peer-reviewed medical literature, there is adequate data demonstrating the benefit from adjuvant chemotherapy in patients with stage III colon cancer. However, it remains controversial whether adjuvant chemotherapy has a role in treating patients with stage II colon cancer. Currently, the decision to treat with adjuvant chemotherapy focuses on the specific features of the cancer such as high grade pathology, lymphovascular invasion, or the presence of obstruction or perforation. In this patients case, none of these features were present. The Oncotype DX Colon Cancer Assay is a 12-gene panel that aims to help predict the risk of recurrence in stage II patients and guide the need for adjuvant chemotherapy. However, there is a paucity of support in the clinical studies showing that use of the Oncotype DX results in superior health outcomes when compared to the standard of care. For these reasons, the Oncotype DX Colon Cancer Assay provided on 2/14/18 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 30-year-old female enrollee has requested reimbursement for bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician
that this patient had a history of bilateral hallux valgus deformities, and she underwent surgery for correction of this painful deformity. The provider elected to perform the modified McBride procedure combined with a chevron osteotomy of the left great toe on 6/10/19 and a modified McBride procedure combined with a scarf osteotomy of the right great toe on 7/29/19. | Overturned | Experimental | Summary Reviewer 3
A 30-year-old female enrollee has requested reimbursement for bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient had a history of bilateral hallux valgus deformities, and she underwent surgery for correction of this painful deformity. The provider elected to perform the modified McBride procedure combined with a chevron osteotomy of the left great toe on 6/10/19 and a modified McBride procedure combined with a scarf osteotomy of the right great toe on 7/29/19. Fluoroscopy was utilized for both surgical procedures. Hallux valgus deformity is a common chronic problem, and its chief complaint is pain. The procedures performed, including the modified McBride, chevron osteotomy, and scarf osteotomy, are all current procedures with documented good results. There is sufficient support for the services at issue in this clinical setting. Thus, bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19 was likely to have been more beneficial than other treatment options.
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A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis. | Upheld | Experimental | Summary Reviewer 3
A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis. The physician reviewer found that the use of fecal calprotectin is supported for management of patients with ulcerative colitis to prevent invasive interventions such as colonoscopy. A randomized, prospective, controlled trial by Lasson and colleagues evaluating patients with ulcerative colitis showed lower relapse rate than control when using calprotectin to direct management with medications. Another prospective study by Costa and colleagues showed that unlike in Crohns disease, fecal calprotectin was sensitive and specific for prediction of relapse in ulcerative colitis, making it a useful tool for non-invasive monitoring. In this patients case, the test allowed for assessment of ulcerative colitis disease activity without colonoscopy. For these reasons, fecal calprotectin testing performed on 11/22/17 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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A 58-year-old male enrollee has requested authorization and coverage for endovenous laser therapy procedure. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who is diagnosed with venous insufficiency.
the 58-year-old male enrollee has requested authorization and coverage for endovenous laser therapy procedure. The Health Insurer has denied this request indicating that the | Overturned | Medical Necessity | Summary Reviewer
A 58-year-old male enrollee has requested authorization and coverage for endovenous laser therapy procedure. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who is diagnosed with venous insufficiency. The physician reviewer found that the 58-year-old male enrollee has requested authorization and coverage for endovenous laser therapy procedure. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who is diagnosed with venous insufficiency.
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A 61-year-old female enrollee has requested reimbursement for the office visits provided on 5/20/16, 8/25/16, and 11/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees hypothyroidism, Hashimotos thyroiditis, menopause syndrome, and iron deficiency anemia.
the records document that the office visit on 5/20/16 was indicated to follow the patients thyroid levels. | Overturned | Experimental | Summary Reviewer 1
A 61-year-old female enrollee has requested reimbursement for the office visits provided on 5/20/16, 8/25/16, and 11/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees hypothyroidism, Hashimotos thyroiditis, menopause syndrome, and iron deficiency anemia. The physician reviewer found that the records document that the office visit on 5/20/16 was indicated to follow the patients thyroid levels. However, there is a lack of evidence supporting follow-up office visits on 8/25/16 and 11/17/16. Although it is important to follow thyroid stimulating hormone (TSH) and free T4 in patients on LT4 and T3, it is unclear why these need to be checked every three months for this patient. Given these findings, the office visit on 5/20/16 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while the office visits on 8/25/16 and 11/17/16 were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, a portion of the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be partially overturned.
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A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma (laboratory service code 84999) rendered on 8/25/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma.
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that this patient is a 58-year-old male with a history of malignant melanoma of 0.51 mm Breslow depth on the left anterior shoulder. The provider recommended gene testing to assess the metastatic risk of the tumor. The patient has requested reimbursement for DecisionDx-Melanoma (laboratory service code 84999) rendered on 8/25/17. The Health Insurer denied this request and reported that the services at issue were considered investigational for evaluating this patients medical condition. | Upheld | Experimental | Summary Reviewer 2
A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma (laboratory service code 84999) rendered on 8/25/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma.
. The physician reviewer found that this patient is a 58-year-old male with a history of malignant melanoma of 0.51 mm Breslow depth on the left anterior shoulder. The provider recommended gene testing to assess the metastatic risk of the tumor. The patient has requested reimbursement for DecisionDx-Melanoma (laboratory service code 84999) rendered on 8/25/17. The Health Insurer denied this request and reported that the services at issue were considered investigational for evaluating this patients medical condition. The use of this type of testing is not considered to be a standard of care in the evaluation of assessing a patients melanoma. The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. As such, the utilization of DecisionDx-Melanoma gene assay cannot be expected to affect the treatment or health outcome of this patients melanoma. Therefore, DecisionDx-Melanoma (laboratory service code 84999) rendered on 8/25/17 was not likely to have been more effective for the evaluation of this patients medical condition than any available standard therapy. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 75-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing
performed on 5/26/21. The Health Insurer has denied this request and reported that the services
at issue were investigational for the evaluation of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 2
A 75-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing
performed on 5/26/21. The Health Insurer has denied this request and reported that the services
at issue were investigational for the evaluation of the enrollees medical condition. The physician
reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous
melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for
those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be
amenable to excision but this suggests a high risk for the development of metastatic disease in
the future. Such patients may be observed or treated with interferon-alpha. The data on
DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node
biopsy. There has also been some lack of consistency between various genes being used as
biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the
treatment algorithm beyond standard staging techniques. This is also the consensus opinion of
the National Comprehensive Cancer Network guidelines. Therefore, DecisionDx-Melanoma
testing performed on 5/26/21 was not likely to have been more beneficial than any available
standard therapy.
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A 25-year-old male enrollee has requested reimbursement for quantitative EEG (brain mapping) performed from 7/02/20 through 8/25/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeAaas medical condition.
that the patient has history of major depressive disorder with suicidal ideations. He has been previously hospitalized for psychiatric care for the same. The patient has already received traditional care for this diagnosis. | Upheld | Experimental | Summary Reviewer 2
A 25-year-old male enrollee has requested reimbursement for quantitative EEG (brain mapping) performed from 7/02/20 through 8/25/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeAaas medical condition. The physician reviewer found that the patient has history of major depressive disorder with suicidal ideations. He has been previously hospitalized for psychiatric care for the same. The patient has already received traditional care for this diagnosis. There is evidence that quantitative EEG can have findings which can be used a biomarker for suicidality. EEG activity in theta band has clinical potential as a biomarker for preventing suicide. Furthermore, high-gamma rhythm has the potential to be used as a biomarker for screening suicidality. The use of quantitative EEG findings can be used to treat patients with neurofeedback. Therefore, quantitative EEG (brain mapping) performed from 7/02/20 through 8/25/20 was likely to have been more beneficial than other available standard therapy.
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The patient is a 28-year-old male who presented to his provider on 9/2/22. The patient has
requested reimbursement for magnetic resonance (e.g. proton) imaging, any joint of lower
extremity, without contrast material, on 9/21/22. The Health insurer has denied this request and
reported that the services at issue were not medically necessary for the evaluation of this patient.
In this case, the patient had left ankle and right knee pain for
years that did not respond to
treatment. Notes dated 9/2/22 reported left posterior
tibial tendon tenderness and a positive Tinels sign, suggesting impingement. Subsequent MRI
imaging of the ankle did not show structural issues. The patient reported that the MRIs resulted
in a diagnosis of Tarsal Tunnel syndrome and referral for EMG. An EMG was conducted by a
neurologist that confirmed the diagnosis. Notes dated 9/2/22 also reported severe right knee
medial joint line tenderness and patellofemoral pain. MRI of the right knee revealed a deep root
tear of the meniscus requiring arthroscopy. | Overturned | Medical Necessity | Summary Reviewer
The patient is a 28-year-old male who presented to his provider on 9/2/22. The patient has
requested reimbursement for magnetic resonance (e.g. proton) imaging, any joint of lower
extremity, without contrast material, on 9/21/22. The Health insurer has denied this request and
reported that the services at issue were not medically necessary for the evaluation of this patient.
The physician reviewer found that the submitted documentation supports the medical necessity
of a portion of the services at issue. In this case, the patient had left ankle and right knee pain for
years that did not respond to conservative treatment. Notes dated 9/2/22 reported left posterior
tibial tendon tenderness and a positive Tinels sign, suggesting impingement. Subsequent MRI
imaging of the ankle did not show structural issues. The patient reported that the MRIs resulted
in a diagnosis of Tarsal Tunnel syndrome and referral for EMG. An EMG was conducted by a
neurologist that confirmed the diagnosis. Notes dated 9/2/22 also reported severe right knee
medial joint line tenderness and patellofemoral pain. MRI of the right knee revealed a deep root
tear of the meniscus requiring arthroscopy. While the American College of Radiology (ACR) notes
that MRI is usually not appropriate in the setting of chronic ankle or knee pain without prior x-
rays, given this patients multi-year history of prolonged and unexplained ankle and knee pain,
the services at issue were medically indicated. Therefore, magnetic resonance imaging of the
right knee and the left ankle were medically necessary for the evaluation of this patient.
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A 69-year-old female enrollee has requested authorization and coverage for Prolia 60 mg/mL syringe. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of the enrollees medical condition. | Overturned | Medical Necessity | Summary Reviewer
A 69-year-old female enrollee has requested authorization and coverage for Prolia 60 mg/mL syringe. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Osteoporosis is an increasingly widespread condition. Fractures are the most dangerous aspect of osteoporosis, and this can lead to acute and chronic pain as well as increased mortality. While bisphosphonate therapy has been available for the treatment of osteoporosis for a number of years, a newer medication, denosumab (Prolia) is a fully human monoclonal antibody that has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. While both bisphosphonates and Prolia have been shown to be effective at improving bone mineral density and reducing the risk of subsequent fractures, recent data suggests that Prolia has superior efficacy, particularly in the region of the spine. Because this patient has severe osteoporosis, with lowest bone mineral density in the region of the spine, and has sustained a fracture in the past, Prolia is medically indicated. Therefore, Prolia 60 mg/mL syringe is medically necessary for the treatment of this patient.
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The patient is a 67-year-old male with medical history of gastroesophageal reflux disease (GERD), hyperlipidemia, and hernia repair. The patient has requested reimbursement for inpatient hospital stay provided from 6/18/21 through 6/20/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient.
. The patient had abdominal pain, nausea, and vomiting, as well as imaging concerning for at least partial small bowel obstruction. However, CT scan of the abdomen and pelvis did not show pathology such as gastrointestinal perforation, abscess, or toxic megacolon. He had gradual advancement of diet, and was tolerating a full liquid diet by 6/20/21. | Upheld | Medical Necessity | Summary Reviewer
The patient is a 67-year-old male with medical history of gastroesophageal reflux disease (GERD), hyperlipidemia, and hernia repair. The patient has requested reimbursement for inpatient hospital stay provided from 6/18/21 through 6/20/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the inpatient level of care is not supported based on the submitted documentation. The patient had abdominal pain, nausea, and vomiting, as well as imaging concerning for at least partial small bowel obstruction. However, CT scan of the abdomen and pelvis did not show pathology such as gastrointestinal perforation, abscess, or toxic megacolon. He had gradual advancement of diet, and was tolerating a full liquid diet by 6/20/21. Although uncomplicated small bowel obstruction may have been present, the patient did not have clinical gastrointestinal bleeding, peritonitis, sepsis, or other complications warranting inpatient level of care. The standard of care for uncomplicated small bowel obstruction was performed, including intravenous fluids and gradual advancement of diet, and all could have been performed without the inpatient level of care, at the observation level of care. The measures that were undertaken, including observation, monitoring, laboratory testing, imaging, and advancement of diet, could have been performed without the inpatient level of care. For these reasons, inpatient hospital stay provided from 6/18/21 through 6/20/21 was not medically necessary for the treatment of this patient.
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A 61-year-old female enrollee has requested reimbursement for Nuvigil provided from 1/1/15 through 8/1/15. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees circadian rhythm disorder, shift work type. | Upheld | Medical Necessity | Summary Reviewer
A 61-year-old female enrollee has requested reimbursement for Nuvigil provided from 1/1/15 through 8/1/15. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees circadian rhythm disorder, shift work type. The physician reviewer found that Nuvigil has been provided to this patient for circadian rhythm disorder, shift work type. This medication has shown efficacy and has an indication for this condition (Czeisler, et al; Morgenthaler, et al). However, this patients records do not support a diagnosis of shift work sleep disorder. Further, there is no reference to any other condition such as narcolepsy or treated obstructive sleep apnea which may support an indication for Nuvigil. Given this lack of information, the Nuvigil provided to this patient from 1/1/15 through 8/1/15 was not medically necessary. Consistent with these findings, the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
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patient is a 48-year-old female who has been diagnosed with atopic dermatitis of the face. She has failed therapy with topical triamcinolone. The patient has requested authorization and coverage for Dupixent prefilled syringe 300 mg/2 ml. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. | Overturned | Medical Necessity | Summary Reviewer
The patient is a 48-year-old female who has been diagnosed with atopic dermatitis of the face. She has failed therapy with topical triamcinolone. The patient has requested authorization and coverage for Dupixent prefilled syringe 300 mg/2 ml. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that Dupixent has been approved by the U.S. Food and Drug Administration for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. There are very few treatments approved for this condition, and this drug has quickly become a standard/preferred therapeutic option by dermatologists in the community. The data supporting its use in moderate-to-severe atopic dermatitis is substantial, and it has a favorable side effect profile in comparison to other systemic agents that would be available to this patient. Based on the submitted documentation, the patient appears to be a good candidate for this treatment. Therefore, Dupixent prefilled syringe 300 mg/2 ml is medically necessary for the treatment of this patient.
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An 18-year-old male enrollee has requested reimbursement for residential treatment services provided from 8/05/15 through 11/30/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.
score of 2. The patient had some risk of harm. He has a history of intermittent suicidal ideation and has a history of writing a suicide letter. The patient denied any current or future suicide plans at the residential treatment center. With regards to functional status, the records support a score of 3. The patient had moderate functional impairment during the dates of service at issue. The patient was increasing his substance use of marijuana and was failing out of school. Per documentation, he did have struggles interacting with staff at the beginning of his stay at the residential treatment center.
The patient had comorbidities of concussions, chronic nausea and vomiting, and cannabis use. His chronic nausea and vomiting is thought to have led the patient to increase his substance use due to marijuana helping with his nausea and vomiting. | Upheld | Medical Necessity | Summary Reviewer
An 18-year-old male enrollee has requested reimbursement for residential treatment services provided from 8/05/15 through 11/30/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. To objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 2. The patient had some risk of harm. He has a history of intermittent suicidal ideation and has a history of writing a suicide letter. The patient denied any current or future suicide plans at the residential treatment center. With regards to functional status, the records support a score of 3. The patient had moderate functional impairment during the dates of service at issue. The patient was increasing his substance use of marijuana and was failing out of school. Per documentation, he did have struggles interacting with staff at the beginning of his stay at the residential treatment center. In terms of comorbidity, the records support a score of 3. The patient had comorbidities of concussions, chronic nausea and vomiting, and cannabis use. His chronic nausea and vomiting is thought to have led the patient to increase his substance use due to marijuana helping with his nausea and vomiting. The patients marijuana use has had a significant impact on his presenting problems. With regards to the patients recovery environment, the records support a score of 2 in terms of environmental stress. The patient had a good relationship with his mother and father. In terms of environmental support, the records support a score of 2. The patient has supportive parents who are willing to participate in treatment if asked to do so. With regards to resiliency, the records support a score of 3. The patient had equivocal resiliency and response to treatment. In terms of acceptance and engagement, the records support a score of 3. At the time of admission, the patient expressed his desire to be treated in a less restrictive environment. The patient was passive in his treatment and limited his interaction with the staff. Thus, the records support a composite score of 18. Based on these criteria, the patient would meet criteria for an intensive outpatient program and could have been treated in a less restrictive environment. The patient continued to need treatment, but this could have been accomplished at a lower level of care. Therefore, residential treatment services provided from 8/05/15 through 11/30/15 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | 1 |
The parent of a five-year-old male enrollee has requested authorization and coverage for Gammagard 20 gm infused every four weeks for one year, 40 units per dose for a total of 520 units. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition.
patient has a history of recurrent sinopulmonary infections, with | Overturned | Medical Necessity | Summary Reviewer
The parent of a five-year-old male enrollee has requested authorization and coverage for Gammagard 20 gm infused every four weeks for one year, 40 units per dose for a total of 520 units. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that PANS represents sudden onset of psychiatric symptoms, typically consistent with obsessive-compulsive disorder, following infection with a number of agents, including group A streptococcus and mycoplasma. This represents a broader variation of PANDAS. An article by Calaprice and colleagues noted that the majority of practitioners utilized both short-term and long-term courses of antibiotics, intravenous immunoglobulin, particularly for patients with immunoglobulin G (IgG) deficiencies, plasmapheresis, psychotropic medications, and psychotherapy. Complementary and alternative medicines, including gluten-free diet and homeopathic medications, were also utilized. The authors noted that intravenous immunoglobulin therapy was reported to have been beneficial in reducing PANS symptoms for many patients, but was most beneficial, and most enduringly beneficial, for the subset with IgG deficiencies. This patient has a history of recurrent sinopulmonary infections, with reproducible laboratory evidence of common variable immune deficiency. He also meets criteria for PANDAS/PANS. Based on the current standard of care for patients with this constellation of disorders, monthly intravenous immunoglobulin therapy as prescribed is medically appropriate. Therefore, Gammagard 20 gm infused every four weeks for one year, 40 units per dose for a total of 520 units is medically necessary for the treatment of this patient. | 1 |
patient is a 62-year-old male who presented with prostate cancer and underwent a radical prostatectomy in 2008. The patient has requested authorization and coverage for radiation therapy for prostate cancer. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. | Overturned | Medical Necessity | Summary Reviewer
The patient is a 62-year-old male who presented with prostate cancer and underwent a radical prostatectomy in 2008. The patient has requested authorization and coverage for radiation therapy for prostate cancer. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that this patients pathologic specimen reveals lymph node disease with no evidence of distant metastases. Due to the localized disease presentation, radiation therapy is indicated and is potentially curative. The radiation technique of intensity modulated radiation therapy is necessary due to the patient receiving prior radiation to the pelvic region. Intensity modulation in this setting is necessary to reduce the dose to the surrounding small bowel, which will reduce long-term toxicities from the treatment. As this is a relatively rare clinical presentation with nodal only relapse of prostate cancer, there is a lack of phase 3 studies or guidelines that specifically address treatment in this scenario. However, there are multiple large retrospective series that indicate that salvage radiation therapy in this setting can result in long-term cure rates with minimal toxicities. Therefore, radiation therapy for prostate cancer is medically necessary for the treatment of this patient. | 1 |
A 58-year-old female enrollee has requested reimbursement for Afirma Thyroid Fine Needle Aspiration Analysis gene testing performed on 11/18/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. | Overturned | Experimental | Summary Reviewer 1
A 58-year-old female enrollee has requested reimbursement for Afirma Thyroid Fine Needle Aspiration Analysis gene testing performed on 11/18/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. All told, Afirma Thyroid Fine Needle Aspiration Analysis gene testing performed on 11/18/14 was likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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A 27-year-old female enrollee has requested authorization and coverage for proton beam therapy for six weeks. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees breast cancer. | Upheld | Experimental | Summary Reviewer 3
A 27-year-old female enrollee has requested authorization and coverage for proton beam therapy for six weeks. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees breast cancer. The physician reviewer found that the medical evidence to support the effectiveness of proton beam radiation therapy in this clinical setting is lacking. National Comprehensive Cancer Network Guidelines do not suggest the use of proton beam for breast cancer. Although proton beam radiation therapy has been shown to be safe and effective for certain tumors that are adjacent to critical structures, there is insufficient clinical peer-review literature for supporting its use for the treatment of breast carcinoma. Also, the ASTRO emerging technology committee report does not include proton therapy for breast cancer. Instead, there are other established alternative therapies available such as conventional conformal or intensity modulated radiation therapy for treatment of breast cancer. These conventional methods have been shown to be safe and effective for the adjuvant treatment of breast cancers. All told, proton beam therapy for six weeks is not likely to be superior over the conventional methods for treatment of this patient. Therefore, for the reasons stated above, the requested services are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 70-year-old female enrollee has requested reimbursement for radiofrequency ablation of the right side performed on 5/25/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees varicose veins.
This patient has C2 disease with symptoms and anterior accessory saphenous vein reflux. | Overturned | Experimental | Summary Reviewer 2
A 70-year-old female enrollee has requested reimbursement for radiofrequency ablation of the right side performed on 5/25/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees varicose veins. The physician reviewer found there is sufficient support for the services at issue in this clinical setting. This patient has C2 disease with symptoms and anterior accessory saphenous vein reflux. Standard of care supports treatment in this patients case. Generally, the indications for treatment include pain or other discomfort, edema, varix hemorrhage, recurrent superficial phlebitis, stasis dermatitis, or ulceration. The medical evidence supports treatment of patients with C2 disease. Per the current evidence, radiofrequency ablation of the right side performed on 5/25/16 was likely to have been more efficacious than other treatment options. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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A 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral corneal ectasia. | Overturned | Experimental | Summary Reviewer 3
A 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral corneal ectasia. The physician reviewer found that the medical literature supports the efficacy of the services at issue in this clinical setting. Collagen crosslinking is a standard treatment for progressive keratoconus and ectasia after refractive surgery. It was approved by the U.S. Food and Drug Administration in 2016. There are many case series showing the efficacy in post Lasik ectasia. In order to determine if a patient is an appropriate candidate for collagen crosslinking, one must have evidence of progression, which can be based on refraction, keratometry, topography, or objective testing measures. In this patients case, the records from the patients provider noted evidence of progression. Given the likelihood of progression, collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16 were likely to have been the most effective treatment option for this patient.
Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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A 49-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health outpatient treatment provided from 4/19/18 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. | Upheld | Medical Necessity | Summary Reviewer
A 49-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health outpatient treatment provided from 4/19/18 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, a mental disorder is defined as a syndrome characterized by clinically significant disturbance in an individuals cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. According to the clinical information presented for this review, this definition of a mental disorder is not met per the documentation. The records do not document the medical necessity of the services at issue due to overall lack of support for the presence of a mental illness. Therefore, mental health outpatient services from 4/19/18 forward were not and are not medically necessary for the treatment of this patient. | 0 |
A 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. | Overturned | Experimental | Summary Reviewer 1
A 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers especially in patients with extremely and heterogeneously dense tissue. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done using two-dimensional imaging alone. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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A 31-year-old female enrollee has requested reimbursement for the collagen cross links, any method (CPT code 82523) provided on 1/10/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees left ankle pain status De Novo procedure for osteochondral lesion of the medial talar dome. | Upheld | Experimental | Summary Reviewer 1
A 31-year-old female enrollee has requested reimbursement for the collagen cross links, any method (CPT code 82523) provided on 1/10/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees left ankle pain status De Novo procedure for osteochondral lesion of the medial talar dome. The physician reviewer found that serum or urine collagen crosslinks or biochemical markers are unproven to assess risk of fracture, predict bone loss, or assess response to anti-resorptive therapy. The current medical literature shows there is evidence that standard methods for measuring bone turnover markers are sufficiently sensitive to reliably determine individual treatment responses. There is insufficient evidence from controlled studies that bone turnover marker measurement improve adherence to treatment or improve health outcomes by reducing fracture rate. All told, the collagen cross links, any method (CPT code 82523) provided on 1/10/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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patient is a 30-year-old male with a history of extensive physical and emotional abuse dating back to childhood and a history of alcohol as well as drug abuse. He was currently not working as a private basketball trainer due to COVID-19 and associated restrictions.
. He has been involved in excessive use of substances. There was no suicidal or homicidal ideation.
. The patient had relationship problems as a result of his drinking. His relationship with his girlfriend had suffered, and there was strain with his mother as well. He was motivated to achieve stability in these relationships and was engaged in family therapy.
In terms of comorbidity, the records
score of 3. He has insulin dependent diabetes mellitus. There was nothing in the notes
He was unable to work due to COVID-19 restrictions and was financially
. The patientas mother participated in treatment.
With regard to resiliency and treatment history, the records support a score of 3. The patient has had emotional problems since childhood and has struggled with substance use.
In terms of engagement and recovery status, the records support a score of 2. He had | Overturned | Medical Necessity | Summary Reviewer
The patient is a 30-year-old male with a history of extensive physical and emotional abuse dating back to childhood and a history of alcohol as well as drug abuse. He was currently not working as a private basketball trainer due to COVID-19 and associated restrictions. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a.
stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.
In terms of risk of harm, the records support a score of 3. He has been involved in excessive use of substances. There was no suicidal or homicidal ideation.
With regard to functional status, the records support a score of 3. The patient had relationship problems as a result of his drinking. His relationship with his girlfriend had suffered, and there was strain with his mother as well. He was motivated to achieve stability in these relationships and was engaged in family therapy.
In terms of comorbidity, the records support a score of 3. He has insulin dependent diabetes mellitus. There was nothing in the notes to indicate that his blood sugars were unstable.
With regard to level of stress of the recovery environment, the records support a score of 3. He was unable to work due to COVID-19 restrictions and was financially dependent on his mother.
In terms of level of support of the recovery environment, the records support a score of 2. The patientas mother participated in treatment.
With regard to resiliency and treatment history, the records support a score of 3. The patient has had emotional problems since childhood and has struggled with substance use.
In terms of engagement and recovery status, the records support a score of 2. He had acceptance of his illness and was engaged in his treatment. He was motivated to get better.
Thus, the records support a composite score of 19. Intensive outpatient program level of care was medically indicated. Therefore, intensive outpatient program services provided from 7/15/20 through 10/08/20 were medically necessary for the treatment of this patient.
| 1 |
The parent of a 15-year-old female enrollee has requested reimbursement for acute inpatient mental health treatment provided from 2/13/20 through 3/19/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions.
The patient had a serious risk of harm, due to consistent deficits in ability to care for herself.
. The patient had severe functional impairment as evidenced by severe weight loss due to refusal of food and nasogastric tube feedings, leading to dehydration and requiring medical hospitalization.
The patient had a moderately stressful environment. The records noted serious illness for | Overturned | Medical Necessity | Summary Reviewer
The parent of a 15-year-old female enrollee has requested reimbursement for acute inpatient mental health treatment provided from 2/13/20 through 3/19/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In terms of risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to consistent deficits in ability to care for herself. With regard to functional status, the records support a score of 5. The patient had severe functional impairment as evidenced by severe weight loss due to refusal of food and nasogastric tube feedings, leading to dehydration and requiring medical hospitalization. In terms of comorbidity, the records support a score of 5 due to her medical status being compromised by food refusal. With regard to recovery environment, the records support a score of 3. The patient had a moderately stressful environment. The records noted serious illness for prolonged period, leading to months of hospitalization. In terms of environmental support, the records support a score of 2 due to her parents participation in treatment and treatment planning. With regard to resiliency and treatment history, the records support a score of 5. The records document persistence of symptoms despite past treatment at high levels of care for extended periods of time. In terms of treatment acceptance and engagement, the records support a score of 4. The patient refused medications and food and refused to cooperate with behavioral interventions. Therefore, the patient has a total score of 28. Due to severe functional impairment and severe comorbidity, the recommended level of care is medically managed residence-based services. This is consistent with the level of care offered in an inpatient setting. Therefore, acute inpatient mental health treatment provided from 2/13/20 through 3/19/20 was medically necessary for the treatment of this patient. | 1 |
A 63-year-old male enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees liver cancer. | Overturned | Experimental | Summary Reviewer 1
A 63-year-old male enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees liver cancer. The physician reviewer found the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The most recent National Comprehensive Cancer Network (NCCN) guidelines for colon cancer state that In patients with a limited number of liver or lung metastases, radiotherapy can be considered in highly selected cases. For small liver lesions, it is well-established that SBRT yields high rates of control. In addition, radiation techniques other than SBRT will not likely allow adequate dose escalation to sufficiently treat the tumor or provide adequate normal tissue sparing. For this patient, with a lesion near the hilum radiofrequency ablation (RFA) is not an option as the tumor cannot be sufficiently heated as the vascular flow dissipates the heat, and there is a risk of vascular trauma such that RFA is contraindicated and conventional radiation is likely to be less efficacious. Therefore, SBRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| 1 |
The patient is a 59-year-old female who has been diagnosed with a uterine leiomyosarcoma. She was initially diagnosed in August 2001, at hysterectomy, with the finding of a 1.5 cm leiomyosarcoma. After surgery, she received radiation therapy. She was then well until mid-2016 when a computed tomography scan revealed a pelvic mass, confirmed by positron emission tomography scan. Biopsy was positive for recurrent leiomyosarcoma. She underwent debulking surgery and was started on adriamycin with olaratumab. Her tissue was sent for FoundationOne assay. The patient has requested reimbursement for the FoundationOne test performed on 11/14/16. The Health Insurer has denied reimbursement on the basis that services at issue were investigational for the evaluation of this patients medical condition. | Upheld | Experimental | Summary Reviewer 1
The patient is a 59-year-old female who has been diagnosed with a uterine leiomyosarcoma. She was initially diagnosed in August 2001, at hysterectomy, with the finding of a 1.5 cm leiomyosarcoma. After surgery, she received radiation therapy. She was then well until mid-2016 when a computed tomography scan revealed a pelvic mass, confirmed by positron emission tomography scan. Biopsy was positive for recurrent leiomyosarcoma. She underwent debulking surgery and was started on adriamycin with olaratumab. Her tissue was sent for FoundationOne assay. The patient has requested reimbursement for the FoundationOne test performed on 11/14/16. The Health Insurer has denied reimbursement on the basis that services at issue were investigational for the evaluation of this patients medical condition. There is a lack of support for the services at issue in this clinical setting. FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician, or yields a result that is reliably clinically beneficial. There are various non-randomized studies exploring the value of molecular profiling but these studies are not definitive or compelling as to the efficacy of the assay. A randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. Finding a mutation does not guarantee that a treatment directed at that mutation will produce a clinically meaningful response. All told, the FoundationOne test performed on 11/14/16 was not likely to have been more efficacious than other methods of evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 1 |
The patient is a 57-year-old male with AL amyloidosis with cardiac involvement. Prior treatment has included Cytoxan, dexamethasone, Velcade, and Kyprolis. The provider has recommended treatment with daratumumab (Darzalex). The patient has requested authorization and coverage for Darzalex. The Health Insurer has denied this request indicating that the requested medication is considered investigational. | Overturned | Experimental | Summary Reviewer 2
The patient is a 57-year-old male with AL amyloidosis with cardiac involvement. Prior treatment has included Cytoxan, dexamethasone, Velcade, and Kyprolis. The provider has recommended treatment with daratumumab (Darzalex). The patient has requested authorization and coverage for Darzalex. The Health Insurer has denied this request indicating that the requested medication is considered investigational. As noted in the medical literature, Darzalex is an anti-CD38 monoclonal antibody used in multiple myeloma. Case reports and a retrospective study described the safety and efficacy of daratumumab in patients with relapsed or refractory AL amyloidosis (Sher, et al; Kaufman, et al). Toxicity was similar to that observed in patients with multiple myeloma. All told, the requested Darzalex is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| 1 |
A 50-year-old male enrollee has requested authorization and coverage for Repatha SureClick. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypercholesterolemia. | Upheld | Medical Necessity | Summary Reviewer
A 50-year-old male enrollee has requested authorization and coverage for Repatha SureClick. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypercholesterolemia. The physician reviewer found that Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient does not fit either of those criteria. The presence of coronary calcium does not equate to coronary obstruction, and there is no documented obstructive coronary stenosis or clinical cardiovascular disease, such as stroke, myocardial infarction, angina, ischemia on stress testing, or prior coronary revascularization. PCSK9 inhibitors have not been adequately studied in other patient populations, such as this patient with an elevated calcium score but no documented clinical cardiovascular disease. The current guidelines do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Thus, Repatha SureClick is not medically necessary for the treatment of this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | 1 |
The patient is a 41-year-old female. The patient has requested reimbursement and prospective
authorization and coverage for inpatient residential treatment from 5/1/21 and forward. The
Health Insurer has denied this request and reported that the services at issue were not and are
not medically necessary for the treatment of this patient.
noted moderate functional impairment due to the patient
consistently choosing to isolate herself, although improving in her ability to fulfill responsibilities
The patient has significant comorbidity. The
patient is overweight, which can be worsened by her medications, and reports urinary
ned by her treatment. The records did not note substance use issues. | Upheld | Medical Necessity | Summary Reviewer
The patient is a 41-year-old female. The patient has requested reimbursement and prospective
authorization and coverage for inpatient residential treatment from 5/1/21 and forward. The
Health Insurer has denied this request and reported that the services at issue were not and are
not medically necessary for the treatment of this patient. The physician reviewer found that The
American Association of Community Psychiatrists Level of Care Utilization System (LOCUS)
provides a reliable framework for determining the appropriate level of care for adults needing
mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-
pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional
status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors
and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score
is then used to determine the level of care needed. With regard to risk of harm, the records
support a score of 3. The patient has a significant risk of harm, due to consistent evidence of self-
neglect and need for direction from program staff to assist in patients self-care, without suicidal
ideation or a history of past suicide attempts. In terms of functional status, the records support
a score of 3. The documentation noted moderate functional impairment due to the patient
consistently choosing to isolate herself, although improving in her ability to fulfill responsibilities
and manage her basic needs while participating in treatment in a structured setting. With regard
to comorbidity, the records support a score of 3. The patient has significant comorbidity. The
patient is overweight, which can be worsened by her medications, and reports urinary issues,
which may be worsened by her treatment. The records did not note substance use issues. In
terms of level of stress of the recovery environment, the records support a score of 2. The patient
has a mildly stressful environment. She has been at the RTC for quite some time now, since at
least 2020. It appears that the patient was unable to maintain a job prior to her admission and
continues to have some discomfort about her responsibilities at the program, repeatedly
checking with staff for direction. With regard to level of support of the recovery environment,
the records support a score of 3 as the patients mother is actively involved, but the patient
isolates herself and has limited ability to utilize resources independently. In terms of resiliency
and treatment history, the records support a score of 3. The patient has moderate or equivocal
response to treatment, as she has been hospitalized psychiatrically several times in the past and
her partial recovery has been maintained only with strong professional support in structured
settings. With regard to treatment acceptance and engagement, the records support a score of
4. The patient is unable to accept the reality of her illness but acknowledges some difficulties
associated with it, although reporting that these difficulties are the result of a UTI. Thus, the
patient has a total score of 21. In this case, the recommended level of care is medically monitored
nonresidential services. Therefore, inpatient residential treatment from 5/1/21 and forward was
not and is not medically necessary for the treatment of this patient.
| 1 |
patient is a 61-year-old female who presented to her provider on 8/18/22. The patient has
requested authorization and coverage for tonsillectomy and adenoidectomy surgery for
removal of growth on tonsil. | Upheld | Medical Necessity | Summary Reviewer
The patient is a 61-year-old female who presented to her provider on 8/18/22. The patient has
requested authorization and coverage for tonsillectomy and adenoidectomy surgery for
removal of growth on tonsil. The physician reviewer found that submitted documentation does
not support the medical necessity of the requested service. Patel and colleagues report that adult
tonsillectomy may be indicated for infections, biopsies, tonsillar stones, and obstructive sleep
apnea. Bowers and Schaitkin note that mucoceles may be managed with surgical excision,
marsupialization, laser ablation, cryotherapy, intralesional steroid injection, and sclerosing
agents. Given that current medical literature does not support tonsillectomy and adenoidectomy
for treatment of a superficial mucocele, the requested service is not medically indicated.
Therefore, tonsillectomy and adenoidectomy surgery for removal of growth on tonsil is not
medically necessary for the treatment of this patient. | 1 |
A 43-year-old male enrollee has requested authorization and coverage for the medication Ocrevus injection 300/10 mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees remitting relapsing multiple sclerosis.
patient only has a history of taking the medication Copaxone for disease modification since 1999.
The provider states a concern that the patient is positive for the John Cunningham virus. | Upheld | Medical Necessity | Summary Reviewer
A 43-year-old male enrollee has requested authorization and coverage for the medication Ocrevus injection 300/10 mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees remitting relapsing multiple sclerosis. The physician reviewer found that as per the medical literature and the submitted information by the patients provider, Ocrevus is a medication that has been shown as beneficial for treatment of relapsing remitting multiple sclerosis. However, the record shows that this patient only has a history of taking the medication Copaxone for disease modification since 1999. As such, there may be other multiple sclerosis medications that may be as clinically effective as Ocrevus. An alternate medication, fingolimod, has been shown as beneficial in treating relapsing remitting multiple sclerosis. The documentation provided does not show that this patient has had an adequate trial and failure of fingolimod. While this patient has a history of hypertension, it is not a contraindication to the medication fingolimod. Additionally, fingolimods prescribing parameters include close monitoring of medication administration, especially with the first dose, to mitigate any potential adverse effects. Moreover, Ocrevus also has significant side effects including increased risk of certain types of cancer. The provider states a concern that the patient is positive for the John Cunningham virus. However, there is also the possibility that this patient may develop progressive multifocal leukoencephalopathy or PML with Ocrevus, as it is an immunosuppressant. In general, all multiple sclerosis disease modifying medications have clinical implications or side effect profiles. In this patients case, the documentation provided does not show an adequate trial or contraindication to the preferred medication fingolimod. Fingolimod could be a reasonable option with the appropriate clinical evaluation, management, and support for this patient. In sum, the requested medication, Ocrevus injection 300/10 mL is not medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | 1 |
A 68-year-old female enrollee has requested reimbursement and prospective authorization and coverage for epidural injections from 6/06/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees medical condition.
. The patient has extruded disc material as well as a disc protrusion. | Upheld | Medical Necessity | Summary Reviewer
A 68-year-old female enrollee has requested reimbursement and prospective authorization and coverage for epidural injections from 6/06/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient has extruded disc material as well as a disc protrusion. These structural defects are not going to be altered by epidural steroids. The patient has spinal stenosis, and the medical literature has shown that epidural steroid injections do not alter the course of the underlying pathology. Radcliff and colleagues compared patients with lumbar spinal stenosis who received epidural steroid injections with patients who did not receive epidural injections during the first three months of the study. The authors noted a worse outcome in the steroid treated group. The current medical evidence does not support the services at issue in this clinical setting. All told, epidural injections from 6/06/16 forward were not and are not medically indicated for the treatment of this patient. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
The parent of 10-year-old male enrollee has requested reimbursement for biofeedback treatment services provided from 3/05/18 through 5/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 1
The parent of 10-year-old male enrollee has requested reimbursement for biofeedback treatment services provided from 3/05/18 through 5/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that attention deficit/hyperactivity disorder is thought to be the most common psychiatric disorder of school-age children. Although the cause is unknown, there are many theories under investigation involving brain anatomy and chemistry. Genetics and environmental factors may also play important roles. Neurofeedback has been extensively studied in the attention deficit/hyperactivity disorder population. Previous meta-analyses have contradicted the methods and results from those that came prior, making it difficult to come to a consensus regarding the efficacy of this treatment technique. Bussalb and colleagues concluded that neurofeedback is an effective treatment for attention deficit/hyperactivity disorder, with studies showing a statistically significant improvement on assessment. More intense treatment was found to increase clinical efficacy. Micoulaud-Franchi and colleagues noted improvement in the inattention dimension of attention deficit/hyperactivity disorder symptoms. Therefore, biofeedback treatment services provided from 3/05/18 through 5/14/18 was likely to have been superior over other available treatment options.
| 0 |
A 25-year-old male enrollee has requested authorization and coverage for upper jaw surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has been diagnosed with obstructive sleep apnea syndrome. | Overturned | Medical Necessity | Summary Reviewer
A 25-year-old male enrollee has requested authorization and coverage for upper jaw surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has been diagnosed with obstructive sleep apnea syndrome. The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. Studies have shown that the presence of abnormalities in the anterior maxilla results in a high nasal floor, which constricts the nasal passageways and causes increased nasal airway resistance. Surgical correction results in improved nasal breathing which is a result of a widened airway space brought about by maxillary arch expansion. This may be accomplished by a number of techniques which may include rapid palatal expansion, surgical assisted rapid palatal expansion, and segmental Le Fort I osteotomies. The submitted documentation notes an intolerance to CPAP and an RDI score of 23.8. Given this patients symptoms, surgical correction is indicated. In sum, the requested upper jaw surgery is medically necessary for the treatment of this patients medical condition.Therefore, for the reasons stated above, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. | 1 |
A 27-year-old female enrollee has requested reimbursement for genetic testing including methylenetetrahydrofolate reductase (MTHFR) gene analysis, common variants, and factor V Leiden mutation testing provided on 7/1/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for bleeding disorder.
This patient has a family history of a prothrombin gene mutation. | Overturned | Experimental | Summary Reviewer 2
A 27-year-old female enrollee has requested reimbursement for genetic testing including methylenetetrahydrofolate reductase (MTHFR) gene analysis, common variants, and factor V Leiden mutation testing provided on 7/1/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for bleeding disorder.
The physician reviewer found that there is support for a portion of the services at issue in this clinical setting. This patient has a family history of a prothrombin gene mutation. Most clinicians would recommend testing for all five major thrombophilias, which includes factor V Leiden mutation. It is not uncommon for patients to carry more than one mutation. Testing for factor V Leiden mutation is likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Regarding MTHFR mutation, homozygosity for these genetic variants is a relatively common cause of mildly elevated plasma homocysteine levels in the general population, often occurring in association with serum folate levels in the low normal range. High quality epidemiologic studies have not found a significant increase in venous thromboembolism risks among individuals homozygous for MTHFR polymorphisms. As such, testing for MTHFR is unlikely to be more beneficial than any available standard of care. Therefore, a portion of the genetic testing provided on 7/1/17 was likely to be more effective than the standard therapy available. Specifically, common variants and factor V Leiden mutation are more likely to be effective than the available standard therapy. Based upon the information set forth above, a portion of the services at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be partially overturned.
| 1 |
A 61-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 2
A 61-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. In sum, DecisionDx-Melanoma testing performed on 10/31/18 was not likely to have been more beneficial than other methods of evaluating this patient.
| 0 |
A 59-year-old female enrollee has requested authorization and coverage for Alvesco 160 mcg inhaler, 1 puff twice per day for one year. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition.
The medical records indicate that this patient has tried another inhaled corticosteroid which was associated with increased symptoms of fatigue, and her symptoms were well maintained | Overturned | Medical Necessity | Summary Reviewer
A 59-year-old female enrollee has requested authorization and coverage for Alvesco 160 mcg inhaler, 1 puff twice per day for one year. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Alvesco (ciclesonide) has been approved by U.S. Food and Drug Administration for the treatment of persistent asthma. Ciclesonide is converted to an active metabolite desisobutyryl-ciclesonide in the lungs. The anti-inflammatory effect of desisobutyryl-ciclesonide is much higher than ciclesonide. Therefore, the local effect of the metabolite is higher, with lower systemic side effects. Ciclesonide has favorable pharmacokinetic and pharmacodynamic properties as inhaled corticosteroid, including low oral bioavailability, high plasma protein binding and rapid systemic clearance, high pulmonary deposition and distribution, and long pulmonary residence duration. These advantageous properties make ciclesonide an effective treatment option with low side effects. The medical records indicate that this patient has tried another inhaled corticosteroid which was associated with increased symptoms of fatigue, and her symptoms were well maintained on ciclesonide. Therefore, it is medically appropriate to maintain the patient on the current ciclesonide to minimize side effects and improve asthma symptoms. Therefore, Alvesco 160 mcg inhaler, one puff twice per day for one year is medically necessary for the treatment of this patient. | 1 |
The patient is an 80-year-old male with a history of psoriatic arthritis and osteoarthritis of both
knees with associated chronic bilateral knee pain. The patient has requested reimbursement for
hyaluronan injections (Synvisc-One) performed on 9/09/21.
In this case, the medical records dated 9/09/21 state that the patient had
received Synvisc-One injections into both knees in the past with good results. Therefore, he
presented with recurrent bilateral knee pain for additional injections. | Overturned | Medical Necessity | Summary Reviewer
The patient is an 80-year-old male with a history of psoriatic arthritis and osteoarthritis of both
knees with associated chronic bilateral knee pain. The patient has requested reimbursement for
hyaluronan injections (Synvisc-One) performed on 9/09/21. The physician reviewer found that
an exhaustive review of the current medical literature pertaining to viscosupplementation
reveals mixed results. Evidence from eight systematic reviews and six randomized controlled
trials indicates that although viscosupplementation may relieve knee pain in some individuals
with osteoarthritis, it is not known as to which individuals will benefit. Different studies have
tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make
it more effective. Guidelines from organizations such as the American Academy of Orthopedic
Surgeons indicate that the evidence is not conclusive. In light of the foregoing,
viscosupplementation can only be recommended in individuals with a history of lasting benefit
from prior injections and in carefully selected cases where everything else has been tried and the
options are limited. In this case, the medical records dated 9/09/21 state that the patient had
received Synvisc-One injections into both knees in the past with good results. Therefore, he
presented with recurrent bilateral knee pain for additional injections. There is sufficient support
for the services at issue in this clinical setting. Therefore, hyaluronan injections (Synvisc-One)
performed on 9/09/21 were medically necessary for the treatment of this patient.
| 1 |
The parent of a 14-year-old female enrollee has requested reimbursement for genetic testing performed on 4/30/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees melanoma. | Upheld | Medical Necessity | Summary Reviewer
The parent of a 14-year-old female enrollee has requested reimbursement for genetic testing performed on 4/30/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees melanoma. The physician reviewer found that the current medical evidence does not support the services at issue. This patient had an early stage melanoma. The National Comprehensive Cancer Network states while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. In addition, the use of DecisionDx-Melanoma testing has not been validated in children. Thus, genetic testing performed on 4/30/18 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld. | 0 |
A 64-year-old female enrollee has requested reimbursement for collagen crosslinks testing performed on 11/18/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. | Overturned | Experimental | Summary Reviewer 1
A 64-year-old female enrollee has requested reimbursement for collagen crosslinks testing performed on 11/18/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that Osteoporosis is a condition of thinning of the bones which leads to increased risk of fracture. Bone mineral density (BMD) assessment, via dual-energy x-ray absorptiometry (DEXA) is the standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. The medical evidence suggests that biochemical markers may be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. The medical evidence supports the services at issue in this clinical setting. Therefore, collagen crosslinks testing performed on 11/18/17 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| 0 |
The patient is a 51-year-old female with a long history of obsessive-compulsive disorder, major depressive disorder, generalized anxiety disorder, insomnia related to obsessive-compulsive disorder and tardive dyskinesia that is the result of previous medications used to treat her obsessive-compulsive disorder. Since 2017, treatment for her significantly worsening obsessive-compulsive disorder symptoms have included duloxetine, Lexapro, mirtazapine, paroxetine, propranolol, sertraline and venlafaxine. Antidepressant treatments made her feel worse and increased her anxiety. Gabapentin was not effective. The records noted that Abilify was not effective. Latuda was effective but caused tardive dyskinesia. The records document significant functional decline, including significant anhedonia, inability to get out of bed, and difficulty with sleep. The patient was started on a trial of Nuedexta, and her obsessive-compulsive disorder and depression were significantly ameliorated. She has requested authorization and coverage for Nuedexta 20-10 mg capsules. The Health Insurer has denied this request and reported that the requested medication is not medically
exta (45 mg and 10 mg, respectively) every 12 hours found that, after 10 weeks, 45% of subjects had experienced remission and 35% had experienced response. The paper
the antidepressant effects of various glutamatergic modulators such as Nuedexta. The records document debilitating obsessive-compulsive disorder and depression, significant anhedonia and loss of ability to function. The patient was at risk for inpatient psychiatric admission for her severe symptoms and depression prior to her trial of Nuedexta. The documentation indicates that the patient has treatment | Overturned | Medical Necessity | Summary Reviewer
The patient is a 51-year-old female with a long history of obsessive-compulsive disorder, major depressive disorder, generalized anxiety disorder, insomnia related to obsessive-compulsive disorder and tardive dyskinesia that is the result of previous medications used to treat her obsessive-compulsive disorder. Since 2017, treatment for her significantly worsening obsessive-compulsive disorder symptoms have included duloxetine, Lexapro, mirtazapine, paroxetine, propranolol, sertraline and venlafaxine. Antidepressant treatments made her feel worse and increased her anxiety. Gabapentin was not effective. The records noted that Abilify was not effective. Latuda was effective but caused tardive dyskinesia. The records document significant functional decline, including significant anhedonia, inability to get out of bed, and difficulty with sleep. The patient was started on a trial of Nuedexta, and her obsessive-compulsive disorder and depression were significantly ameliorated. She has requested authorization and coverage for Nuedexta 20-10 mg capsules. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the submitted records support the medical necessity of the requested medication. Kadriu and colleagues noted that, An open label, one-arm trial of 20 patients with treatment resistant depression who received oral doses of Nuedexta (45 mg and 10 mg, respectively) every 12 hours found that, after 10 weeks, 45% of subjects had experienced remission and 35% had experienced response. The paper by Henter and colleagues highlighted the evidence supporting the antidepressant effects of various glutamatergic modulators such as Nuedexta. The records document debilitating obsessive-compulsive disorder and depression, significant anhedonia and loss of ability to function. The patient was at risk for inpatient psychiatric admission for her severe symptoms and depression prior to her trial of Nuedexta. The documentation indicates that the patient has treatment resistant depression in addition to her treatment refractory obsessive-compulsive disorder. The use of Nuedexta led to clinically significant improvement in her function, when previous first-line treatments had failed, and in fact, had caused her anxiety to worsen. Therefore, Nuedexta 20-10 mg capsules are medically necessary for the treatment of this patient. | 1 |
A 46-year-old female enrollee has requested reimbursement for injection of platelet-rich plasma performed on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition.
of chronic right ankle pain and bilateral heel pain. Surgery was primarily performed due to the enlarging soft tissue mass over her right lateral ankle. She reported symptoms which were characteristic of chronic plantar fasciitis.
In this case, the patient was being treated for chronic bilateral plantar fasciitis as well as a right ankle soft tissue mass. | Upheld | Experimental | Summary Reviewer 2
A 46-year-old female enrollee has requested reimbursement for injection of platelet-rich plasma performed on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the records document a history of chronic right ankle pain and bilateral heel pain. Surgery was primarily performed due to the enlarging soft tissue mass over her right lateral ankle. She reported symptoms which were characteristic of chronic plantar fasciitis. The medical evidence does not support platelet-rich plasma injections of the ankle and foot in this setting. Moraes and colleagues performed a review of 1,088 patients from 19 clinical trials for multiple conditions. The authors noted that a lack of standardization and varying preparation techniques were areas of concern. The authors concluded that there was insufficient evidence to support platelet-rich therapies for musculoskeletal soft tissue injuries. In this case, the patient was being treated for chronic bilateral plantar fasciitis as well as a right ankle soft tissue mass. Platelet-rich plasma injections were performed to treat chronic bilateral plantar fasciitis which had been refractory to conservative management. The available literature regarding tendinopathies and arthropathies of the foot and ankle do not indicate platelet-rich plasma injections are more beneficial for the treatment of foot and ankle conditions than standard conservative management. In sum, injection of platelet-rich plasma performed on 12/21/18 was not likely to have been of greater benefit than other treatment options.
| 1 |
A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.
this patient has obstructive sleep apnea and has a long palate. The nasal obstruction has been relieved since the sleep study was done in 2017, and an updated sleep study has not been performed. The patient has not been able to tolerate the continuous positive airway pressure device, but it is unclear if he has tried the device after the septoplasty. The Inspire device has been approved for the treatment of obstructive sleep apnea. | Overturned | Experimental | Summary Reviewer 2
A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has obstructive sleep apnea and has a long palate. The nasal obstruction has been relieved since the sleep study was done in 2017, and an updated sleep study has not been performed. The patient has not been able to tolerate the continuous positive airway pressure device, but it is unclear if he has tried the device after the septoplasty. The Inspire device has been approved for the treatment of obstructive sleep apnea. At this point, the patient is not a candidate for the Inspire device given the palate appears to be the larger contributing factor to his sleep apnea compared to the base of tongue. If the patient fails treatment of the palate, and he continues to have sleep apnea and is intolerant of the continuous positive airway pressure, then the patient may become a candidate for the Inspire device at that point. At this time, the superior efficacy of the requested services has not been established. In sum, the requested hypoglossal nerve stimulation or Inspire upper airway stimulation system is not likely to be of greater benefit than other treatment options.
| 1 |
A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 3
A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that based on the recent trials comparing patent foramen ovale closure to antiplatelet therapy, patent foramen ovale closure is superior to antiplatelet therapy for preventing future ischemic events. However, in each of the trials, the patients selected had evidence of definite ischemic infarcts. This patient had only clinical symptoms. Therefore, it is unknown whether antiplatelet therapy alone may be superior or equal to patent foramen ovale closure in this population. If recurrent symptoms/transient ischemic attack recur on antiplatelet therapy, then patent foramen ovale closure would be appropriate in the absence of any other etiology, such as paroxysmal atrial fibrillation. Thus, patent foramen ovale closure is not likely to be more beneficial than any available standard therapy.
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A 43-year-old male enrollee has requested authorization and coverage for Sovaldi 400 mg, Daklinza 60 mg and Ribavirin 600 mg for 24 weeks. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollee's hepatitis C virus. | Overturned | Medical Necessity | Summary Reviewer
A 43-year-old male enrollee has requested authorization and coverage for Sovaldi 400 mg, Daklinza 60 mg and Ribavirin 600 mg for 24 weeks. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollee's hepatitis C virus. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to nonliver-related comorbid conditions. Per the guidelines, patients with cirrhosis are high priority for therapy, and patients with diabetes mellitus are at risk for fast progression of fibrosis. This patient is interferon-ineligible due to anxiety. The guidelines recommend that cirrhotic interferon-ineligible patients with genotype 2 hepatitis C who have failed Sovaldi/Ribavirin regimens should be treated with Sovaldi/Daklinza and Ribavirin for 24 weeks. This is based partially on the results of two clinical trials (Sulkowski et al and Wyles et al). Delay in treatment may result in decreased survival (Jezequel et al). For these reasons, the requested treatment with Sovaldi 400 mg, Daklinza 60 mg, and Ribavirin 600 mg for 24 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Therefore, I have determined the requested medications are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. | 1 |
A 38-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 11/11/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. | Upheld | Experimental | Summary Reviewer 3
A 38-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 11/11/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that the use biologics such as Remicade in ulcerative colitis has been proven. However, when a patient loses response to Remicade, this may entail increasing the dose. In this case, there is concern as the disease is active and the patient is symptomatic. The concern between total loss of response, low antibody level to the biologic, or a completely different diagnosis entails completely different measures varying from change or increase in dose of biologic to alternate treatment. Moreover, it has been shown in the medical literature that checking for such antibodies helps optimize clinical response by helping achieve a more optimal drug concentration. Given this support, the Anser IFX testing performed on 11/11/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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The patient is a 42-year-old female who presented to her provider on 3/9/22. The records indicated
that the patient noted left thyroid swelling in January 2020. The patient has requested authorization
and coverage for additional thyroid tissue removal surgery. The Health Insurer has denied this
request and reported that the requested service is medically necessary for the treatment of this
patient.
of a fine-needle aspiration (FNA). In this case,
the FNA was suggestive of a follicular neoplasm. | Overturned | Medical Necessity | Summary Reviewer
The patient is a 42-year-old female who presented to her provider on 3/9/22. The records indicated
that the patient noted left thyroid swelling in January 2020. The patient has requested authorization
and coverage for additional thyroid tissue removal surgery. The Health Insurer has denied this
request and reported that the requested service is medically necessary for the treatment of this
patient. This denial is the subject of this appeal and determination. The physician reviewer found
that the submitted documentation supports the medical necessity of the requested service. The
decision to pursue surgical intervention, either total thyroidectomy or lobectomy, is typically based
on the results of a preoperative biopsy in the form of a fine-needle aspiration (FNA). In this case,
the FNA was suggestive of a follicular neoplasm. The dilemma with this diagnosis is that cancer
can only be definitively established on gross tissue architecture, which has historically necessitated
excision of at least the lobe of the thyroid containing the suspicious nodule. However, recent
advances in genetic sequencing have augmented this algorithm. If genetic evaluation of the FNA
establishes a low ROM, many practitioners forgo removal of the thyroid in favor of observation.
In this case, as the genetic testing was noted as suspicious, with a ROM of 50%, performing at
least a lobectomy was appropriate. In many cases of well differentiated thyroid carcinoma, such
as papillary and follicular, lobectomy alone is sufficient for treatment. However, certain factors
necessitate returning to the operating room to remove the opposite thyroid lobe in a completion
thyroidectomy. One of these factors is the size of the cancerous nodule. The American Thyroid
Association (ATA) guidelines for the management of differentiated thyroid carcinoma notes that
for nodules greater than four centimeters, total thyroidectomy is recommended when a FNA is
suggestive of carcinoma, or a completion thyroidectomy when carcinoma is ultimately diagnosed
on lobectomy, as in this case, due to a higher-than-acceptable risk of recurrence (ROR) when the
cancerous nodule is greater than four centimeters. In a systematic review investigating risk factors
for recurrence in follicular thyroid carcinoma, Grnland and colleagues found that the overall rate
of recurrence was 13.6%, with 64.8% of recurrences representing distant metastasis, and
specifically identified a size greater than four centimeters as a statistically significant risk factor
for recurrence. In this clinical setting, given that current medical literature supports completion
thyroidectomy to mitigate the patients risk of recurrence of follicular thyroid carcinoma most
effectively, the requested service is medically indicated. Therefore, additional thyroid tissue
removal surgery is medically necessary for the treatment of this patient.
| 1 |
The parent of an 11-year-old male enrollee has requested reimbursement for the FirstStepDx PLUS test provided on 7/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees attention deficit hyperactivity disorder (ADHD). | Overturned | Experimental | Summary Reviewer 1
The parent of an 11-year-old male enrollee has requested reimbursement for the FirstStepDx PLUS test provided on 7/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found that the clinical utility of CMA is well established, and is now considered first-line genetic tests for patients with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics, the American College of Medical Genetics, the American College of Neurology and the Child Neurology Society (Schaefer, et al; Moeschler, et al; Shevell, et al; Shen, et al). In a study by Coulter and colleagues, a retrospective chart review of CMA testing was performed on patients with developmental delay, intellectual disability, autism spectrum disorders and congenital anomalies. Findings in this study demonstrated that CMA results influenced medical care in the majority of patients by precipitating medical referrals, diagnostic imaging, or specific laboratory testing, supporting the use of CMA as a clinically useful diagnostic test. It is for these reasons, that the FirstStepDx PLUS test provided on 7/6/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| 1 |
A 61-year-old male enrollee has requested authorization and coverage for Tykerb. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. | Overturned | Experimental | Summary Reviewer 2
A 61-year-old male enrollee has requested authorization and coverage for Tykerb. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that salivaray gland tumors are rare. HER2 is expressed in about one-third of salivary gland tumors. Tykerb (lapatinib) is an orally active dual inhibitor of EGFR and HER2. Agulnik and colleagues studied this medication in a phase II trial of 40 patients. Although no responses were observed, 47 percent of patients treated with lapatinib had prolonged tumor stabilization of at least six months. Since disease progression prior to enrollment was required in this trial, the prolonged tumor stabilization may be more likely due to true drug effect. The medical evidence supports the requested medication in this patients case. In sum, Tykerb is likely to be of greater benefit than other available treatment options.
| 1 |
A 64-year-old female enrollee has requested reimbursement for injection, anesthetic agent, greater occipital nerve, provided on 6/05/19 and 6/12/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition.
The patient has been diagnosed with seizure disorder and Chiari malformation. The records document occipital headaches when supine. | Upheld | Experimental | Summary Reviewer 3
A 64-year-old female enrollee has requested reimbursement for injection, anesthetic agent, greater occipital nerve, provided on 6/05/19 and 6/12/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. The patient has been diagnosed with seizure disorder and Chiari malformation. The records document occipital headaches when supine. The use of occipital nerve blocks is typically indicated for greater occipital neuralgia and currently does not have any indicated for Chiari malformation. The sub-occipital headaches are mostly likely secondary to the Chiari malformation. The records do not support the diagnosis of greater occipital neuralgia. Thus, injection, anesthetic agent, greater occipital nerve provided on 6/05/19 and 6/12/19 were not likely to have been more beneficial than other treatment options.
| 1 |
A 32-year-old male enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees central nervous system (CNS) germinoma. | Overturned | Medical Necessity | Summary Reviewer
A 32-year-old male enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees central nervous system (CNS) germinoma. The physician reviewer found that IMRT is a tool that providers can use when there is concern about sparing normal tissues from high dose exposure. IMRT generally implies inverse planning algorithms to maximize dose to the target and minimize dose to normal tissues. In the medical literature, Sakanaka and colleagues evaluated IMRT for CNS germinoma. The authors found that IMRT demonstrated better conformality in target coverage and better sparing of normal brain with IMRT in the treatment of CNS germinoma than 3D conformal radiation therapy. For CNS germinoma, the prescribed dose is relatively low and still below the accepted tolerance of the brainstem, optic nerves, retina and below the risk for brain necrosis. However, the target is complex in shape and IMRT would be more conformal in this clinical setting. For these reasons, the requested IMRT for this case is an accepted standard and supported as medically necessary for treatment of this patients CNS germinoma. In sum, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| 1 |
A 38-year-old female has requested reimbursement for laboratory testing performed on 7/06/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who had a history of recurrent pregnancy loss.
The records indicate that the patient had a second trimester pregnancy loss.
the patient had Non Invasive Prenatal Screen Testing, the results of which were negative. Given the patient had studies suggestive of a structural anomaly within the uterus and that she subsequently underwent a septum removal, | Upheld | Experimental | Summary Reviewer 3
A 38-year-old female has requested reimbursement for laboratory testing performed on 7/06/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who had a history of recurrent pregnancy loss. The physician reviewer found the current medical evidence fails to support the services at issue in this setting. The records indicate that the patient had a second trimester pregnancy loss. The likely etiology of this loss would be suggestive of a spontaneous or inherited genetic mutation or a complication of implantation/placental development. Secondary to other early genetic testing results the patient had Non Invasive Prenatal Screen Testing, the results of which were negative. Given the patient had studies suggestive of a structural anomaly within the uterus and that she subsequently underwent a septum removal, it is possible that was the underlying etiology. Per the American College of Obstetricians and Gynecologists, testing for inherited thrombophilias in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence. Although there may be an association in these cases, there is insufficient clinical evidence that antepartum prophylaxis with unfractionated heparin or low molecular weight heparin prevents recurrence in these patients. The only superseding issue would be if the patient had a personal history of venous thromboembolism or a first-degree relative with a history of high-risk thrombophilia. No such history appears to be presented in this case. Thus, laboratory testing performed on 7/06/15 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 1 |
A 39-year-old female enrollee has requested reimbursement for emergency and post stabilization services and care provided from 5/01/19 through 5/04/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition.
. This patient sustained a left trimalleolar displaced fracture on 5/01/20. She was admitted to inpatient care with severe swelling of the left foot and toes for surgical management. She was provided inpatient care, including ongoing intravenous fluids, lower extremity neurovascular checks, preoperative cardiac evaluation, swelling reduction, deep vein thrombosis prophylaxis, and pain management in the preoperative period. She underwent open reduction and internal fixation of the left ankle fractures on 5/04/19 and was subsequently discharged home. | Overturned | Medical Necessity | Summary Reviewer
A 39-year-old female enrollee has requested reimbursement for emergency and post stabilization services and care provided from 5/01/19 through 5/04/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that evidence-based medical literature generally support open reduction and internal fixation of unstable ankle fractures several days to a few weeks after injury. Continued inpatient admission is indicated until acceptable patient status for next level of care is achieved, including pain is absent or adequately managed on oral medications, injuries stabilized as needed (e.g. cast, orthoses), and the patient is ambulatory and can perform activities of daily living or activity at baseline or activity acceptable for next level of care. This patient sustained a left trimalleolar displaced fracture on 5/01/20. She was admitted to inpatient care with severe swelling of the left foot and toes for surgical management. She was provided inpatient care, including ongoing intravenous fluids, lower extremity neurovascular checks, preoperative cardiac evaluation, swelling reduction, deep vein thrombosis prophylaxis, and pain management in the preoperative period. She underwent open reduction and internal fixation of the left ankle fractures on 5/04/19 and was subsequently discharged home. The services provided in the emergency and inpatient setting as outlined above would appropriately be considered acute level of care for treatment of the enrollees acute displaced ankle fracture. Based on the records, emergency and post stabilization services and care provided from 5/01/19 through 5/04/19 were medically necessary for the treatment of this patient. | 1 |
The parent of a 16-year-old female enrollee has requested reimbursement for residential treatment center services from 5/28/16 through 6/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues.
The records available for review noted that the patient was receptive to interventions and actively participated in treatment and programming. The resident complied with her meal plan overall. Per the discharge summary, the patient endorsed the self-harming instances in an attempt to prolong her stay in the treatment center. | Upheld | Medical Necessity | Summary Reviewer
The parent of a 16-year-old female enrollee has requested reimbursement for residential treatment center services from 5/28/16 through 6/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records available for review noted that the patient was receptive to interventions and actively participated in treatment and programming. The resident complied with her meal plan overall. Per the discharge summary, the patient endorsed the self-harming instances in an attempt to prolong her stay in the treatment center. A comparison of medications from 5/18/16 to discharge indicated that these medications could have been administered at an outpatient setting and did not necessitate residential treatment. All told, there is no indication from the reviewed records to reflect that this patient could not have been transitioned to a lower level of care during the period in dispute. Therefore, for the reasons stated above, the services at issue were not medically necessary for treatment of this patient. The Health Insurers denial should be upheld.
| 1 |
A 64-year-old female enrollee has requested reimbursement for residential mental health services provided from 4/6/15 through 5/5/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.
review, the patient demonstrated a complex illness burden that
. In this case, the patient was isolative. She had not been employed in more than 20 years. She had no children. She had limited social support and was the primary care giver for her spouse who suffered from Parkinsons disease. Additionally, the patient had formidable, co-occurring mood and anxiety disorders. | Overturned | Medical Necessity | Summary Reviewer
A 64-year-old female enrollee has requested reimbursement for residential mental health services provided from 4/6/15 through 5/5/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the residential mental health services provided from 4/6/15 through 5/5/15 were medically necessary for treatment of the patients medical condition. Based on the additional documentation submitted for review, the patient demonstrated a complex illness burden that encompassed all elements of the biopsychosocial conceptualization which presented a challenging placement determination. In this case, the patient was isolative. She had not been employed in more than 20 years. She had no children. She had limited social support and was the primary care giver for her spouse who suffered from Parkinsons disease. Additionally, the patient had formidable, co-occurring mood and anxiety disorders. This is of particular relevance since it has been well-established in both clinical practice and the medical literature that anxiety-ridden mood disorders, even without the complication of pathological personality traits, are notoriously difficult to treat and in general have poor outcomes (Fava, et al). The patient remained symptomatic despite the delivery of multiple evidence-based interventions during the episode of illness. Based on the duration of symptoms, relevant clinical history, psychosocial factors and characterological influences, safe and effective care could not have been adequately provided in a less restrictive setting at the time. Thus, the residential mental health services provided from 4/6/15 through 5/5/15 was medically necessary for treatment of the patients behavioral health condition. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| 1 |
A 61-year-old male enrollee has requested reimbursement for the Life Vest provided on 5/23/14. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees congestive heart failure and atrial fibrillation.
The patient has newly diagnosed dilated non-ischemic cardiomyopathy. | Upheld | Experimental | Summary Reviewer 2
A 61-year-old male enrollee has requested reimbursement for the Life Vest provided on 5/23/14. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees congestive heart failure and atrial fibrillation. The physician reviewer found that the Life Vest was not likely to be more beneficial for treatment of this patients condition compared to standard available therapies. The patient has newly diagnosed dilated non-ischemic cardiomyopathy. The Life Vest wearable defibrillator is generally accepted for patients who meet criteria for implantable cardioverter defibrillator (ICD) placement but have a temporary contraindication to device placement, such as infection. There is a lack of randomized, controlled trials supporting use of the wearable defibrillator for patients with a new diagnosis of dilated cardiomyopathy as opposed to optimal medical therapy alone. Based on the registry data by Chung and colleagues, there does not appear to be a significant benefit of the wearable defibrillator for this patients diagnosis. In the registry, there was a very low incidence of appropriate therapies for ventricular arrhythmias for this group of patients. It is recommended that the patient have a trial of optimal medical therapy. Consistent with these findings, the Life Vest provided on 5/23/14 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 1 |
A 53-year-old female enrollee has requested reimbursement for gene testing performed on 11/15/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma.T | Upheld | Experimental | Summary Reviewer 2
A 53-year-old female enrollee has requested reimbursement for gene testing performed on 11/15/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma.The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines note while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low-risk versus high-risk for metastasis, routine (baseline) prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The medical evidence does not support the services at issue in this clinical setting. In sum, gene testing performed on 11/15/16 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 1 |
A 49-year-old male enrollee has requested reimbursement for a positron emission tomography (PET) scan performed on 6/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. | Overturned | Experimental | Summary Reviewer 1
A 49-year-old male enrollee has requested reimbursement for a positron emission tomography (PET) scan performed on 6/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that in general, PET/CT is useful for staging a known malignancy. If indeed the final pathology was a tumor of renal origin, it is not clear the reason such a tumor was not seen on conventional imaging which would usually have been the case. There is a lack of support for the services at issue in this clinical setting. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 64-year-old male enrollee has requested authorization and coverage for functional electrical stimulation cycle ergometer. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees tetraplegia.
the patient has a spinal cord injury that results in reduced mobility and reduced ability to engage in exercise. | Overturned | Medical Necessity | Summary Reviewer
A 64-year-old male enrollee has requested authorization and coverage for functional electrical stimulation cycle ergometer. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees tetraplegia. The physician reviewer found that the patient has a spinal cord injury that results in reduced mobility and reduced ability to engage in exercise. Functional electrical stimulation cycling has been developed as a means to stimulate muscle activity in paralyzed limbs to reproduce physiological effects of exercise. The literature has explored the effects of functional electrical stimulation cycling to determine if this artificial form of exercise has clinical benefit. The net weight of evidence has been positive, showing that functional electrical stimulation cycling promotes improved health status in people with spinal cord injury. There is sufficient support for the requested device in this clinical setting. Thus, the requested functional electrical stimulation cycle ergometer is medically necessary in this patients case. Therefore, the requested device is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. | 1 |
A 58-year-old female enrollee has requested reimbursement for autonomic nerve testing performed on 9/03/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 2
A 58-year-old female enrollee has requested reimbursement for autonomic nerve testing performed on 9/03/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the medical records provided for review does not support the autonomic nerve testing performed on 9/03/15. The available medical records do not indicate any focal neurologic disturbance in regards to motor, sensory, reflex, coordination, gait or cranial nerve or cognitive function. The records do not report by history the presence of any issue of labile blood pressure, orthostatic hypotension, or passing out episodes. There is no indication of neuropathic pain being reported in terms of having hypersensitivity, allodynia. Autonomic nervous system testing is useful for evaluation of autonomic nervous system when there are autonomic nervous system related symptoms. The available medical records provided for review does not support the presence of subjective symptoms consistent with autonomic nervous system abnormality or indicate objective findings on physical examination which support autonomic nervous system dysfunction. In sum, the superior efficacy of autonomic nerve testing performed on 9/03/15 has not been established. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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The patient is a 46-year-old female with chronic pain at the hip joint. The patients pain has reportedly been present since 2011, treated with physical therapy, steroid injections and arthroscopic labral surgeries. A diagnosis of right labral tear was made in 2011. Arthroscopic surgery was recommended in an attempt to repair the labrum. There were multiple complications following this surgery with a total of four surgical procedures in 13 months. Pain in the hip joint continued. In 2015, a fifth surgical procedure was performed with initial improvement in symptoms followed by recurrence in symptoms. X-rays on 12/8/16 demonstrated moderate medial femoral acetabular osteoarthritis with joint space narrowing as well as moderate osteoarthritis with joint space narrowing. The patient has requested authorization and coverage for AmnioFix injection. The Health Insurer has denied this request indicating that the requested service is considered investigational. AmnioFix | Upheld | Experimental | Summary Reviewer 2
The patient is a 46-year-old female with chronic pain at the hip joint. The patients pain has reportedly been present since 2011, treated with physical therapy, steroid injections and arthroscopic labral surgeries. A diagnosis of right labral tear was made in 2011. Arthroscopic surgery was recommended in an attempt to repair the labrum. There were multiple complications following this surgery with a total of four surgical procedures in 13 months. Pain in the hip joint continued. In 2015, a fifth surgical procedure was performed with initial improvement in symptoms followed by recurrence in symptoms. X-rays on 12/8/16 demonstrated moderate medial femoral acetabular osteoarthritis with joint space narrowing as well as moderate osteoarthritis with joint space narrowing. The patient has requested authorization and coverage for AmnioFix injection. The Health Insurer has denied this request indicating that the requested service is considered investigational. AmnioFix is described as a composite amniotic membrane substance containing growth factors unique to placental tissue. AmnioFix has been utilized in the treatment of ocular burns, conjunctival injuries, and in sheet form for wound care. AmnioFix injections have been recommended in a number of orthopedic conditions including plantar fasciitis and Achilles tendonitis. In this particular patient, anatomical changes are likely to have already occurred within the labrum and the patient has joint space narrowing such that molecular level interventions are not likely to have a positive effect. Given these findings, the requested AmnioFix injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 25-year-old male enrollee has requested authorization and coverage for the LINX Reflux Management System. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).
, the patient presents with non-acid dyspepsia as well as GERD, based on pH recording. The records demonstrate that the patient has benefited to a significant degree from acid suppression treatment to the same extent that his pH study showed correlation of acid reflux events and heartburn. | Upheld | Experimental | Summary Reviewer 2
A 25-year-old male enrollee has requested authorization and coverage for the LINX Reflux Management System. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found in this case, the patient presents with non-acid dyspepsia as well as GERD, based on pH recording. The records demonstrate that the patient has benefited to a significant degree from acid suppression treatment to the same extent that his pH study showed correlation of acid reflux events and heartburn. Thus, the patient cannot be considered medically refractory to acid blocker drugs, and does not meet the U.S. Food and Drug Administration (FDA) indication for implantation of the LINX device. In addition, the, implantation of LINX in this clinical setting must be approached with caution given the patients documented complaint of dysphagia. For the reasons provided, the request for the LINX Reflux Management System is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 60-year-old female enrollee has requested reimbursement for the gene test (gene expression profiling) CPT 84999 performed on 12/29/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. | Upheld | Experimental | Summary Reviewer 1
A 60-year-old female enrollee has requested reimbursement for the gene test (gene expression profiling) CPT 84999 performed on 12/29/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is insufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. According to the results of analysis of patients melanoma performed with DecisionDx melanoma, the tumor was classified as Class 1B with a low risk of near-term (within five years) metastatic disease, such as 90% metastasis free rate. According to the standard analysis of such risk, the lesions of 1-2 mm depth have a risk of 80-96%. Although DecisionDx melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. Therefore, the gene test (gene expression profiling) CPT 84999 performed on 12/29/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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The parent of a five-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) therapy provided from 6/5/15 through 12/3/15. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism spectrum disorder (ASD). | Overturned | Medical Necessity | Summary Reviewer
The parent of a five-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) therapy provided from 6/5/15 through 12/3/15. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism spectrum disorder (ASD). The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Reichow and colleagues performed a review showing that early intensive behavioral intervention is effective to increase IQ, improve communication and adaptive skills. Based on the documentation submitted for review, the patient presents with symptoms consistent with autism. Maladaptive behaviors including aggression and tantrums are difficult to treat with other interventions. The research shows that although medications including Risperdal can reduce some of the aggression in children with ASD it does not treat the core symptoms and does not provide long term benefits. Matson and Jang performed a literature review on treating aggression in persons with ASD and found that the most effective interventions were behavioral interventions including ABA therapy. Based on the support in the peer-reviewed literature and the documented regression in behaviors with a reduction of hours, the request for 30 hours per week of ABA was and is medically necessary for treatment of the patients medical condition. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
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A 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer. | Overturned | Experimental | Summary Reviewer 2
A 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed on 9/22/16 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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The parent of a six-year-old male insured has requested reimbursement for Coronavirus COVID-
19 (SARS-CoV-2) respiratory panel performed on 11/8/22. The Health Plan has denied this request
indicating that the requested services are considered investigational for evaluation of the insureds
respiratory illness with concern for SARS-CoV-2 infection. | Overturned | Experimental | Summary Reviewer 1
The parent of a six-year-old male insured has requested reimbursement for Coronavirus COVID-
19 (SARS-CoV-2) respiratory panel performed on 11/8/22. The Health Plan has denied this request
indicating that the requested services are considered investigational for evaluation of the insureds
respiratory illness with concern for SARS-CoV-2 infection. The physician reviewer found that the
use of respiratory panels to diagnose the cause of respiratory symptoms remains of unclear value
when compared to other tests including COVID-19 polymerase chain reaction (PCR). The
recommendations in the medical literature support testing when a patient is immunocompromised,
at high risk of complications from the infection, and when testing could be used to direct therapy.
This patients records fail to adequately document that the patient was immunocompromised, at
high risk of complications from the infection, or that testing was being performed to direct therapy.
As noted by Calderaro and colleagues, The implementation of molecular methods with syndromic
panels has the potential to be a powerful decision-making tool for patient management despite
requiring appropriate use of the test in different patient populations. However, there is a lack of
data to support a clinical indication for the Coronavirus COVID-19 (SARS-CoV-2) respiratory
panel for diagnosis of this patient in lieu of COVID-19 PCR testing. All told, the Coronavirus
COVID-19 (SARS-CoV-2) respiratory panel performed on 11/8/22 was not likely to be more
beneficial for evaluation of the patients medical condition than any available standard therapy.
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The patient is a 16-month-old male who was born by Cesarean section at 32 weeks 3 days gestation. The patients parent has requested reimbursement for physical therapy and speech therapy services provided from 7/22/20 through 8/24/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient.
This patient was born prematurely, at 32 weeks 3 days gestation. He spent four weeks in the NICU, and required a feeding tube. He has documented developmental delays, including gross motor delays, apraxia, poor emotional regulation, and feeding difficulties. | Overturned | Medical Necessity | Summary Reviewer
The patient is a 16-month-old male who was born by Cesarean section at 32 weeks 3 days gestation. The patients parent has requested reimbursement for physical therapy and speech therapy services provided from 7/22/20 through 8/24/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found This patient was born prematurely, at 32 weeks 3 days gestation. He spent four weeks in the NICU, and required a feeding tube. He has documented developmental delays, including gross motor delays, apraxia, poor emotional regulation, and feeding difficulties. Spittle and colleagues noted, Infants born preterm are at increased risk of developing cognitive and motor impairment compared with infants born at term. Early developmental interventions have been provided in the clinical setting with the aim of improving overall functional outcomes for these infants." Woodward and colleagues reported that infants born before 34 weeks of gestation have three times the risk of impairments in multiple developmental domains compared with term infants. Bui and colleagues stated, Preterm children should be screened regularly for developmental delay, and parents of preterm infants should be counseled about the options of early intervention programs, and their potential positive impact on development. The medical evidence supports the services at issue in this clinical setting. Therefore, physical therapy and speech therapy services provided from 7/22/20 through 8/24/20 were medically necessary for the treatment of this patient.
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A 55-year-old female enrollee has requested authorization and coverage for Sirturo. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees mycobacterium avium-intracellulare complex (MAC).
H and Rifampin; the patients records do not show that she has drug resistant TB. Furthermore, Sirturo has potential adverse cardiac effects (Sirturo Pres | Upheld | Medical Necessity | Summary Reviewer
A 55-year-old female enrollee has requested authorization and coverage for Sirturo. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees mycobacterium avium-intracellulare complex (MAC). The physician reviewer found the submitted documentation fails to demonstrate that the patients medical condition meets medical necessity criteria for the requested medication, Sirturo. Sirturo is U.S. Food and Drug Administration (FDA) approved for treatment of drug resistant tuberculosis (TB) resistant to INH and Rifampin; the patients records do not show that she has drug resistant TB. Furthermore, Sirturo has potential adverse cardiac effects (Sirturo Prescribing Information). Moreover, medical studies evaluating the use of Sirturo for treatment of MAC are limited. A study by Philley and colleagues involving patients with atypical mycobacteria who were treated with Sirturo included only 10 patients, and was not blinded, randomized or controlled. Finally, the record indicates that the patients MAC appears stable on CT scan. All told, the requested medication is not medically necessary for treatment of the patients medical condition. Based on the submitted documentation and per accepted clinical guidelines, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
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The patient is a 58-year-old female with a history of gastroesophageal reflux disease (GERD). Evaluation has included esophagogastroduodenoscopy (EGD) in 2017 with a small hiatal hernia, irregular Z-line and histologically mild acute and chronic esophagitis, and minimal to mild Helicobacter pylori-negative gastritis. In 2017, pH testing performed off acid blocker therapy identified a composite DeMeester score of 39.7 and zero correlation of acid reflux events with heartburn. The patient has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational.
This patient has GERD based on pH recording and radiographic criteria. However, she does not have evidence of advanced esophagitis | Upheld | Experimental | Summary Reviewer 2
The patient is a 58-year-old female with a history of gastroesophageal reflux disease (GERD). Evaluation has included esophagogastroduodenoscopy (EGD) in 2017 with a small hiatal hernia, irregular Z-line and histologically mild acute and chronic esophagitis, and minimal to mild Helicobacter pylori-negative gastritis. In 2017, pH testing performed off acid blocker therapy identified a composite DeMeester score of 39.7 and zero correlation of acid reflux events with heartburn. The patient has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational. The LINX device received U.S. Food and Drug Administration (FDA) premarketing for patients with GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. This patient has GERD based on pH recording and radiographic criteria. However, she does not have evidence of advanced esophagitis nor was there correlation noted between acid reflux events and heartburn. Given that only 64% of patients achieved either normalization of or at least 50% reduction in esophageal acid exposure with LINX (1), this patients lack of correlation of symptoms with acid exposure does not support an indication for the requested procedure. Thus, the requested LINX procedure is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 57-year-old male enrollee has requested authorization and coverage for implanted upper airway stimulation device (Inspire). The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). | Upheld | Experimental | Summary Reviewer 3
A 57-year-old male enrollee has requested authorization and coverage for implanted upper airway stimulation device (Inspire). The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that the requested device (Inspire) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although the patient meets certain clinical criteria for implantation of a hypoglossal nerve stimulator, the records do not document that the patient has tried and failed other potential surgical options such as uvulopalatopharyngoplasty (UPPP). In addition, a record of the patients complete physical examination is not included and the clinical status of the patients tonsils are unknown. For the reasons provided, the implanted upper airway stimulation device (Inspire) device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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The patient is a 35-year-old male who was initially admitted on 1/07/22 for treatment of
amphetamine use disorder. The patient has requested reimbursement for residential substance
abuse treatment at Harmony Place provided from 1/21/22 through 1/30/22.
The patient did not require
withdrawal management during this portion of his treatment.
biomedical conditions.
The patient does not have active medical problems. The patient
emotional, behavioral, or
cognitive conditions. The patient has been diagnosed with depressive disorder and stimulant-
induced psychosis. Records indicate that he was severely depressed with impaired activities of
daily living and difficulty participating in groups. He was prone to sleeping and isolating himself.
He was also delusional about having past lives and needing to be high on methamphetamine to
access these memories. He continued to feel that he needed to use methamphetamine to have
these experiences. He assaulted his mother in December 2021 while high on methamphetamine
and was arrested for elder abuse. The patient meets sub-criteria of mental status permits
participation, and the patients psychiatric condition is stabilizing. However, despite his best
efforts, the patient is unable to control his use. | Overturned | Medical Necessity | Summary Reviewer
The patient is a 35-year-old male who was initially admitted on 1/07/22 for treatment of
amphetamine use disorder. The patient has requested reimbursement for residential substance
abuse treatment at Harmony Place provided from 1/21/22 through 1/30/22. The physician
reviewer found that per the American Society of Addiction Medicine (ASAM) criteria, this patient
met Level 3.5 criteria for residential treatment center services provided from 1/21/22 through
1/30/22. The ASAM criteria focuses on six dimensions to determine the appropriate level of care.
Dimension 1 involves acute intoxication or withdrawal potential. The patient did not require
withdrawal management during this portion of his treatment. The patient met the sub-criteria of
withdrawal needs can be met in Level 3.5 setting. Dimension 2 involves biomedical conditions.
The patient does not have active medical problems. The patient met the sub-criteria of
biomedical problems, if any, are stable. Dimension 3 involves emotional, behavioral, or
cognitive conditions. The patient has been diagnosed with depressive disorder and stimulant-
induced psychosis. Records indicate that he was severely depressed with impaired activities of
daily living and difficulty participating in groups. He was prone to sleeping and isolating himself.
He was also delusional about having past lives and needing to be high on methamphetamine to
access these memories. He continued to feel that he needed to use methamphetamine to have
these experiences. He assaulted his mother in December 2021 while high on methamphetamine
and was arrested for elder abuse. The patient meets sub-criteria of mental status permits
participation, and the patients psychiatric condition is stabilizing. However, despite his best
efforts, the patient is unable to control his use...with attendant probability of imminent danger.
The resulting level of dysfunction is so severe that it precludes the patients participation in a less
structured and intensive level of care. Dimension 4 involves readiness to change. The patient
was admitted voluntarily for treatment only after his family staged an intervention after he
assaulted his mother. He then went to a motel for three weeks to use methamphetamine daily
prior to agreeing to enter treatment. He has not worked in three years due to his
methamphetamine usage. This patient was noted to have poor insight into his
methamphetamine usage and to have limited readiness to change. He had minimal awareness of
negative consequences of using. The patient met the sub-criteria of because of the intensity and
chronicity of the addictive disorder, he has limited insight and little awareness of the need for
continuing care or the existence of his substance use and need for treatment, and thus has
limited readiness to change. Dimension 5 involves relapse, continued use, and continued
problem potential. This patient had prior attempts at treatment with residential stays in 2020
and 2021. His longest sobriety was seven months. He had not been able to identify relapse
triggers. He was noted to have minimal insight into the role that his psychiatric diagnosis of
depression played in his using methamphetamine. His methamphetamine usage has been severe
in that he has been unable to work for three years and is completely reliant on his parents. He
assaulted his mother in December while high and then spent days in jail. He then continued to
use for three more weeks after his release from jail. The patient met the sub-criteria of the
patient does not recognize relapse triggers and lacks insight into the benefits of continuing care,
and is therefore not committed to treatment. His continued substance use poses an imminent
danger of harm to self or others in the absence of 24-hour monitoring and structured support.
Dimension 6 involves recovery environment. He had been staying in motels after his family kicked him out of the house due to assaulting his mother. He is unemployed and has no current income.
He is socially isolated and has no friends or sources of social support. He was noted to be avoidant
of others and had limited participation during treatment. The patient met the sub-criteria of the
patients social network is characterized by significant social isolation or withdrawal, such that
recovery goals are assessed as unachievable at a less intensive level of care. All told, residential
substance abuse treatment at Harmony Place provided from 1/21/22 through 1/30/22 was
medically necessary for the treatment of this patient.
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A 52-year-old female enrollee has requested authorization and coverage for gene test (gene expression profiling) performed on 9/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has been diagnosed with cutaneous melanoma. | Upheld | Experimental | Summary Reviewer 1
A 52-year-old female enrollee has requested authorization and coverage for gene test (gene expression profiling) performed on 9/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has been diagnosed with cutaneous melanoma. The physician reviewer found that there is a lack of support in the medical literature for the services at issue in this patients case. The test claims to determine risk of recurrence for early melanoma. However, there is a lack of data to support using adjuvant therapy in similar patients based on risk of recurrence. Adjuvant therapy is based on stage and not on the risk of recurrence as determined by this test. Moreover, the literature does not support a therapeutic advantage of this test over the standard options since this test is not designed to change or alter therapy nor alter surveillance regardless of risk. Furthermore, prospective randomized data for determination of recurrence is lacking in this test. All told, the gene test (gene expression profiling) performed on 9/20/16 was not likely to have been more beneficial than the established alternatives available for the evaluation of this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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The patient is a 45-year-old male who was admitted voluntarily on 8/02/19 for anxiety, depression, and binge type alcohol use. The patient has requested reimbursement for residential treatment from 8/02/19 through 9/13/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient.
patient had a one-day period of binge drinking a few days before presenting to the facility for admission. His last day of drinking had been three months prior. He had a history of transient suicidal ideation when intoxicated and was not suicidal throughout his admission. | Upheld | Medical Necessity | Summary Reviewer
The patient is a 45-year-old male who was admitted voluntarily on 8/02/19 for anxiety, depression, and binge type alcohol use. The patient has requested reimbursement for residential treatment from 8/02/19 through 9/13/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. In terms of risk of harm, the records support a score of 3. This patient had a one-day period of binge drinking a few days before presenting to the facility for admission. His last day of drinking had been three months prior. He had a history of transient suicidal ideation when intoxicated and was not suicidal throughout his admission. With regard to functional status, the records support a score of 3. He had been involved in extramarital affair with a client and was having significant discord with his wife as a result. He was still working, but had occasional episodes of neglecting parenting responsibilities. There were no significant neurovegetative symptoms, and he was diagnosed with an adjustment disorder at the facility. In terms of medical, addictive, and psychiatric comorbidity, the records support a score of 3. Due to significant comorbidity due to his binge drinking of alcohol. With regard to level of stress of the recovery environment, the records support a score of 3. He has had conflicts with his wife due to her discovering the extramarital affair. He lived in the family home with his children. He and his wife were in counselling to reconcile. In terms of level of support of the recovery environment, the records support a score of 2. He had an outpatient therapist. He has support from his wife, his family and the community. With regard to treatment and recovery history, the records support a score of 3. The patient had an equivocal response to treatment and recovery management.
In terms of engagement and recovery status, the records support a score of 1. The patient had optimal engagement and recovery. He was willing to be in treatment and had understanding and acceptance of illness and its effect on function. Thus, the patient has a composite score of 18. This score indicates that high-intensity community-based services were medically necessary. Services which would be included in this level of care are described as intensive outpatient programs. Therefore, residential treatment from 8/02/19 through 9/13/19 was not medically necessary for the treatment of this patient.
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A 23-year-old female enrollee has requested reimbursement for intraoperative monitoring on
7/25/22. The Health Insurer has denied this request and reported that the service at issue was
investigational for the treatment of the enrollees spastic quadriparesis secondary to cerebral palsy
and spastic dislocation of the right hip.
, the patient is a 23-year-old female with spastic quadriparesis secondary to cerebral palsy and spastic
dislocation of right hip.
In this
case, the patient had spastic dislocation of the right hip and was treated by orthopedic surgery.
Surgical procedures included varus derotational osteotomy of the right proximal femur, | Overturned | Experimental | Summary Reviewer 3
A 23-year-old female enrollee has requested reimbursement for intraoperative monitoring on
7/25/22. The Health Insurer has denied this request and reported that the service at issue was
investigational for the treatment of the enrollees spastic quadriparesis secondary to cerebral palsy
and spastic dislocation of the right hip. The physician reviewer found that in this case, the patient is a 23-year-old female with spastic quadriparesis secondary to cerebral palsy and spastic
dislocation of right hip. Cerebral palsy is a group of permanent disorders that affect the
development of movement, causing a limitation of activity. Spastic quadriparesis secondary to
cerebral palsy occurs when a patient has spasticity and motor difficulties affecting all four
extremities. There are many complications that can occur in a patient with cerebral palsy, including
orthopedic disorders such as hip subluxation, dislocation, foot deformities, and scoliosis. In this
case, the patient had spastic dislocation of the right hip and was treated by orthopedic surgery.
Surgical procedures included varus derotational osteotomy of the right proximal femur,
periacetabular osteotomy, lengthening of the hip adductors and iliopsoas, intraoperative nerve
monitoring, and peripheral nerve block. Intraoperative nerve monitoring is a technique applied
during a surgical procedure to continuously evaluate nerve signals to use as an early warning sign
of nerve injury. There are several types of intraoperative nerve monitoring, including motor evoked
potentials, somatosensory evoked potentials, electromyography, and anterior root muscle
response. The evidence supporting the use of intraoperative nerve monitoring during surgical
procedures varies in the medical literature depending on type of surgery. For surgeries that pertain
to the hip, there is evidence that intraoperative nerve monitoring is effective at helping prevent
nerve damage, especially in high-risk cases. In this case, given the patients history of cerebral
palsy and spastic quadriparesis, she is at high-risk for severe deformities. In addition, evidence
demonstrates the benefit of intraoperative nerve monitoring for surgical procedures of the hip. In
this clinical setting of a patient is diagnosed with spastic quadriparesis secondary to cerebral palsy
and spastic dislocation of right hip, intraoperative nerve monitoring is considered standard care.
Therefore, intraoperative monitoring on 7/25/22 was likely to have been more beneficial for
treatment of the patients condition than any available standard therapy.
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The patient is a 63-year-old male with a history of extensive spine surgery, including previous L3-4 laminectomies and foraminotomies as well as an instrumented lumbar fusion at L4-5. The patient has requested authorization and coverage for right L3-L4 foraminotomies.
This patientas provider evaluated the patient and ruled out other sources of the patientas pain. He notes dermatomal pain and sensory changes with meaningful weakness that correlates to the patientas progressive imaging changes with at least moderate foraminal stenosis noted on his most recent MRI scan. The patient attended several physical therapy sessions as noted in the records. The documentation notes that he stopped this as it made his symptoms worse. | Overturned | Medical Necessity | Summary Reviewer
The patient is a 63-year-old male with a history of extensive spine surgery, including previous L3-4 laminectomies and foraminotomies as well as an instrumented lumbar fusion at L4-5. The patient has requested authorization and coverage for right L3-L4 foraminotomies. The physician reviewer found that lumbar foraminotomies have been an accepted surgical treatment strategy for lateral recess/foraminal stenosis for decades. This procedure is well-established for its safety and efficacy. Hu and colleagues recently performed a large retrospective cohort study on patients who underwent primary or repeat foraminotomies to compare their effectiveness. Five hundred and seventy-nine procedures were eligible for evaluation. Using validated outcome measures, the authors observed that primary and repeat foraminotomies have similar successful outcomes. This patientas provider evaluated the patient and ruled out other sources of the patientas pain. He notes dermatomal pain and sensory changes with meaningful weakness that correlates to the patientas progressive imaging changes with at least moderate foraminal stenosis noted on his most recent MRI scan. The patient attended several physical therapy sessions as noted in the records. The documentation notes that he stopped this as it made his symptoms worse. The evidence supporting the role of physical therapy in the care of lumbar radiculopathy is lacking and of low quality despite the fact that it is one of the most prescribed treatments. In a literature review on the topic of conservative therapies for lumbar radiculopathy, Alentado and colleagues noted that there is not strong evidence to support any particular duration of this treatment. They recommend on the basis of the literature, anything from four to eight weeks. On the basis of extensive review of the records and documentation provided, the requested services are medically necessary. The patient had concordant historical and physical examination findings with the reported imaging studies. He was unable to tolerate physical therapy after attempting it. He had neurological weakness that was documented on examination. Therefore, right L3-L4 foraminotomies are medically necessary for the treatment of this patient.
| 1 |
A 24-year-old male enrollee has requested reimbursement for s physiotherapy on 12/7/17 and 12/14/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees arm pain.
In the current case, the patient had chronic symptoms affecting his upper limbs. There were posture issues, potential overuse and anxiety issues. The patient had been undergoing physical therapy for a prolonged period of time, and had maximized the benefit derivable from formal therapy prior to 12/7/17.
. The patient was working on general trunk and core exercises at of the time period in question, with no indications that he could not have been doing these basic conditioning and strengthening exercises independently. He was receiving manual therapy. | Upheld | Medical Necessity | Summary Reviewer
A 24-year-old male enrollee has requested reimbursement for s physiotherapy on 12/7/17 and 12/14/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees arm pain. The physician reviewer found that there documentation provided does not support the medical necessity of the services at issue in this clinical setting. Musicians are at risk for musculoskeletal injury due to overuse and potential underlying factors such as hypermobility (Bird). Early, specialized assessment, often greatly facilitated by examination during actual play of the musical instrument, is considered essential (Rietveld). Key diagnostic issues include recognition of posture related problems, osteoarthritis and entrapment neuropathies. Focused exercise is an appropriate intervention in the setting of some chronic tendinopathies (Childress and Beutler). In addition, relative rest is an important consideration in the setting of overuse conditions. In the current case, the patient had chronic symptoms affecting his upper limbs. There were posture issues, potential overuse and anxiety issues. The patient had been undergoing physical therapy for a prolonged period of time, and had maximized the benefit derivable from formal therapy prior to 12/7/17. Based on the documentation provided, his symptoms were largely correlated with stress/anxiety and relieved by stress reduction interventions more than physical therapy. The patient was working on general trunk and core exercises at of the time period in question, with no indications that he could not have been doing these basic conditioning and strengthening exercises independently. He was receiving manual therapy. Formal manual therapy is not proven to be any more effective than self-applied interventions such as using a foam roller, stretching or applying thermal modalities in the long term. Accordingly, physiotherapy provided on 12/7/17 and 12/14/17 were not medically necessary for treatment of this patients medical condition. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | 1 |
A year-old male enrollee has requested reimbursement for inpatient hospital stay at telemetry level of care from 8/06/18 through 8/09/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition.
that at the time of presentation to the emergency department, the patient reported leg pain with swelling. He did not complain of chest pain or difficulty breathing, but he was tachycardic and febrile with increased respiratory rate. The laboratory studies were significant for an
. Although there was no obvious cardiac ischemia on echocardiogram, the cardiac enzymes were abnormal and the patient was tachycardic.
/18. The patient stabilized medically with treatment, including antibiotics and intravenous fluids. | Overturned | Medical Necessity | Summary Reviewer
A year-old male enrollee has requested reimbursement for inpatient hospital stay at telemetry level of care from 8/06/18 through 8/09/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that at the time of presentation to the emergency department, the patient reported leg pain with swelling. He did not complain of chest pain or difficulty breathing, but he was tachycardic and febrile with increased respiratory rate. The laboratory studies were significant for an elevated troponin. Although there was no obvious cardiac ischemia on echocardiogram, the cardiac enzymes were abnormal and the patient was tachycardic. Admission to an acute inpatient level of care with telemetry was medically reasonable from 8/03/18 through 8/05/18. The patient stabilized medically with treatment, including antibiotics and intravenous fluids. There was no evidence of significant electrolyte abnormalities, cardiac ischemia or dysrhythmia as of 8/05/18. Therefore, inpatient hospital stay at telemetry level of care from 8/03/18 through 8/05/18 was medically necessary for the treatment of this patient. The medical records fail to demonstrate the medical necessity of inpatient hospital stay at telemetry level of care from 8/06/18 through 8/09/18. | 1 |
A 27-year-old female insured has requested authorization and coverage for Besremi 500 mcg/mL
syringe. A review of the record indicates the insured is currently pregnant and has a history of
essential thrombocythemia. The Health Insurer indicates the requested treatment is considered
investigational for the treatment of the insureds medical condition. Therefore, the Health Insurer
has denied coverage for the requested treatment. | Overturned | Experimental | Summary Reviewer 2
A 27-year-old female insured has requested authorization and coverage for Besremi 500 mcg/mL
syringe. A review of the record indicates the insured is currently pregnant and has a history of
essential thrombocythemia. The Health Insurer indicates the requested treatment is considered
investigational for the treatment of the insureds medical condition. Therefore, the Health Insurer
has denied coverage for the requested treatment. This denial is the subject of this appeal and
determination. The physician reviewer found that the essential thrombocythemia is a
myeloproliferative disorder caused by specific mutations in the hematopoietic stem cells. Essential
thrombocythemia manifests as a high platelet count, which predisposes patients to abnormal
clotting. As noted in the medical literature, there is a large overlap between essential
thrombocythemia and polycythemia vera both in clinical manifestations and in molecular genetics.
The mainstay of treatment is the reduction of the platelet count using hydroxyurea, anagrelide, or
interferon. Pegylated interferon is an alternate formulation of interferon that has less toxicity.
Current medical evidence shows that pegylated interferon can reduce the platelet counts of
essential thrombocythemia patients. Since this patient has been able to tolerate treatment with the
Pegasys formulation, but reports problems with tolerating weekly injections was not tolerated, then
the Besremi is an excellent next choice (Okikiolu, et al.; Penna). Accordingly, the requested
Besremi 500 mcg/mL syringe is likely to be more beneficial for the treatment of the patients
medical condition than any available standard therapy.
| 1 |
The patient is a 43-year-old female with a history of left upper extremity, lower extremity and trunk pain. The provider reports the patients pain is consistent with complex regional pain syndrome (CRPS), autonomic nervous system dysfunction, and gastrointestinal dysfunction. The patient states that since starting treatment with neuromuscular stimulation therapy, she has begun to regain muscle that was atrophied. She can walk short distances without assistance. A 2/20/18 document from her provider reports that the patient had a left knee immobilizer and then crutches for several months which caused atrophy and leg weakness. On physical examination, there was weakness in her right L4, L5, and S1 myotomes and upper body myotomes in C5, C6 and C7. The provider recommended a system called Advanced Recovery Program which is neuromuscular stimulation therapy. The patient has requested authorization and coverage for neuromuscular stimulation therapy. The Health Insurer has denied this request indicating that the requested equipment is not medically necessary.
the provider states the patient had leg weakness from using crutches, | Upheld | Medical Necessity | Summary Reviewer
The patient is a 43-year-old female with a history of left upper extremity, lower extremity and trunk pain. The provider reports the patients pain is consistent with complex regional pain syndrome (CRPS), autonomic nervous system dysfunction, and gastrointestinal dysfunction. The patient states that since starting treatment with neuromuscular stimulation therapy, she has begun to regain muscle that was atrophied. She can walk short distances without assistance. A 2/20/18 document from her provider reports that the patient had a left knee immobilizer and then crutches for several months which caused atrophy and leg weakness. On physical examination, there was weakness in her right L4, L5, and S1 myotomes and upper body myotomes in C5, C6 and C7. The provider recommended a system called Advanced Recovery Program which is neuromuscular stimulation therapy. The patient has requested authorization and coverage for neuromuscular stimulation therapy. The Health Insurer has denied this request indicating that the requested equipment is not medically necessary. There is a lack of trials demonstrating clinical benefit with neuromuscular electrical stimulation for chronic pain. Although the records indicate the patient has some weakness in the upper and lower extremity, there is no evidence of muscle atrophy on physical examination documentation. The provider states that a left knee immobilizer caused the patient atrophy. However, a knee immobilizer on the right is not likely to affect all of the unilateral left L4, L5, and S1 myotomes as indicated in the progress note. Additionally, the provider states the patient had leg weakness from using crutches, which does not explain the unilateral weakness. Moreover, there is no progress notes indicating muscle atrophy on a physical examination. Overall, the available documentation does not support the requested neuromuscular stimulation therapy as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
The patient is a 30-year-old female with moderate-severe rheumatoid arthritis. The patient has requested authorization and coverage for Enbrel SureClick. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient.
a In this case, the records document a history of moderate-severe rheumatoid arthritis. In addition, she has failed DMARD therapy. She previously was treated with methotrexate, sulfasalazine and hydroxychloroquine, with uncontrolled disease.
. She was placed on the TNFi, Humira, which was ineffective. She was then placed on an alternate TNFi, Enbrel SureClick. On 7/29/20, office visit notes indicate that Enbrel SureClick was helping to control rheumatoid arthritis. | Overturned | Medical Necessity | Summary Reviewer
The patient is a 30-year-old female with moderate-severe rheumatoid arthritis. The patient has requested authorization and coverage for Enbrel SureClick. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that according to the 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, in established rheumatoid arthritis, aIf disease activity remains moderate or high despite DMARD monotherapy, the recommendation is to use combination traditional DMARDs or add a tumor necrosis factor inhibitor (TNFi) or a non-TNF biologic or tofacitinib (all choices with or without methotrexate, in no particular order of preference), rather than continuing DMARD monotherapy alone.a In this case, the records document a history of moderate-severe rheumatoid arthritis. In addition, she has failed DMARD therapy. She previously was treated with methotrexate, sulfasalazine and hydroxychloroquine, with uncontrolled disease. It is therefore appropriate to consider TNFi therapy in this case based on the guidelines. She was placed on the TNFi, Humira, which was ineffective. She was then placed on an alternate TNFi, Enbrel SureClick. On 7/29/20, office visit notes indicate that Enbrel SureClick was helping to control rheumatoid arthritis. There is sufficient support for the requested medication in this clinical setting. Therefore, Enbrel SureClick is medically necessary for the treatment of this patient.
| 1 |
A 30-year-old female enrollee has requested reimbursement for genetic testing on 4/14/22. The
Health Insurer has denied this request and reported that the service at issue was investigational for
the evaluation of cystic fibrosis of the enrollees fetus. | Overturned | Experimental | Summary Reviewer 1
A 30-year-old female enrollee has requested reimbursement for genetic testing on 4/14/22. The
Health Insurer has denied this request and reported that the service at issue was investigational for
the evaluation of cystic fibrosis of the enrollees fetus. The physician reviewer found that while the
Society for Maternal-Fetal Medicine (SMFM) notes that an ultrasound finding of echogenic bowel
increases the risk of cystic fibrosis in the fetus to by two to three percent, the full gene sequencing
at issue in this case was not likely to have been more beneficial than standard screening with either
limited cystic fibrosis variant panels, consisting of 25 to 150 variants, or expanded mutation panels.
The American College of Obstetrics and Gynecologists (ACOG) reports regarding carrier
screening for genetic conditions that analysis of the cystic fibrosis transmembrane conductance
regulator (CFTR) gene by deoxyribonucleic acid (DNA) sequencing is not appropriate for routine
carrier screening. The ACOG further notes that this type of testing generally is reserved for patients
with cystic fibrosis, patients with negative carrier screening results but a family history of cystic
fibrosis, especially if family test results are not available, males with congenital bilateral absence
of the vas deferens, or newborns with a positive newborn screening result when mutation testing
using the standard 23-mutation panel has a negative result. Therefore, genetic testing on 4/14/22
was not likely to have been more beneficial for evaluation of the patients condition than any
available standard therapy.
| 0 |
A 21-year-old female enrollee has requested reimbursement for the Game Ready system provided on 9/10/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 3
A 21-year-old female enrollee has requested reimbursement for the Game Ready system provided on 9/10/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the Game Ready cryocompression device provides icing and compression for an extremity after surgery. Although both compression and icing are beneficial for the patient after surgical intervention, there is a lack of evidence in the peer-reviewed literature that the supports use of the Game Ready cryocompression device as more beneficial than standard therapies in this clinical setting. Most of the medical literature suggests benefit for patients after joint replacement surgery. All told, there is a lack of peer-reviewed literature that supports the Game Ready cryocompression device as likely to be more beneficial for this patient than icing and wrapping. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 0 |
The patient is a 42-year-old male with a medical history including obesity, dyslipidemia, and fatty
liver. The patient has requested authorization and coverage for Wegovy (semaglutide solution
auto-injector 2.4 mg/0.75 ml). | Upheld | Medical Necessity | Summary Reviewer
The patient is a 42-year-old male with a medical history including obesity, dyslipidemia, and fatty
liver. The patient has requested authorization and coverage for Wegovy (semaglutide solution
auto-injector 2.4 mg/0.75 ml). The physician reviewer found that Semaglutide is an antidiabetic
agent, glucagon-like peptide-1 (GLP-1) receptor agonist. The initial management of individuals
who would benefit from weight loss is a comprehensive lifestyle intervention: a combination of
diet, exercise, and behavioral modification. All patients who would benefit from weight loss
should receive counseling on diet, exercise, and goals for weight loss. When a patient with a
body mass index (BMI) greater than 30 kg/m2 or a BMI of 27-29.9 kg/ms with comorbidities, such
as hypertension or diabetes mellitus, and has failed to achieve weight loss goals through diet and
exercise alone, a pharmacologic therapy is suggested. Wegovy is a brand-named form of
semaglutide that is indicated for chronic management of obesity. It is U.S. Food and Drug
Administration (FDA) approved for the use as an adjunct to diet and exercise in individuals with
a BMI greater 30 kg/m2 or for individuals with a BMI greater than 27 kg/m2 and one or more
weight-associated comorbidity. The initiation of Wegovy is as follows: week 1 through week 4:
0.25 mg once weekly; week 5 through week 8: 0.5 mg once weekly; week 9 through week 12: 1
mg once weekly; week 13 through week 16: 1.7 mg once weekly; and week 17 and ongoing
maintenance dose is 2.4 mg once weekly. Of note, there were discrepancies in the submitted
documentation. The records noted that the patient has been treated with Wegovy, but the
submitted prior authorization form indicated that this is a new prescription and does not start
him at the correct dosage. The provider letter appears to be from supporting staff and not truly
part of the medical records. There are assumptions that the author is making that are not well-
documented in the medical record. The submitted documentation fails to support that the
medication is being prescribed correctly and monitored effectively. Additionally, the
documentation does not indicate that the patient is participating in an appropriate diet/exercise
plan. Therefore, Wegovy (semaglutide solution auto-injector 2.4 mg/0.75 ml) is not medically
necessary for the treatment of this patient.
| 1 |
A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.
this patient presented with a transient ischemic attack in the setting of reported hypertensive urgency. There are no other verified transient ischemic attacks and a reportedly normal head computed tomography (CT) scan. | Upheld | Experimental | Summary Reviewer 2
A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presented with a transient ischemic attack in the setting of reported hypertensive urgency. There are no other verified transient ischemic attacks and a reportedly normal head computed tomography (CT) scan. In patients with transient ischemic attacks and patent foramen ovales, transcatheter closure has been demonstrated to be of mild benefit only in younger patients without another potential source of transient ischemic attack, such as hypertensive urgency, and mainly in patients with transient ischemic attacks despite antiplatelet medication. This patient does not fit those criteria since there is another potential source and his age is greater than 60. In sum, patent foramen ovale closure is not likely to be more beneficial than any available standard therapy.
| 1 |
A 61-year-old male enrollee has requested reimbursement for gene expression profiling performed on 5/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. | Overturned | Experimental | Summary Reviewer 1
A 61-year-old male enrollee has requested reimbursement for gene expression profiling performed on 5/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that patients with superficial bladder cancer are followed with serial cystoscopies and urine cytology. There are a variety of molecular-based markers being studied to improve the results of cytology alone. CxBladder testing has a 93% sensitivity and an 80 to 85% specificity, both of which are better than cytology alone. It is particularly being used in patients whose bladder tumors are deemed to be high risk for recurrence. There is sufficient support for the services at issue in this clinical setting. Therefore, gene expression profiling performed on 5/10/19 was likely to have been more beneficial than other methods of evaluating this patient.
| 0 |
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