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text stringlengths 60 2.6k	decision stringclasses 2 values	appeal_type stringclasses 8 values	full_text stringlengths 206 13.1k	sufficiency_id int64 0 1
A 36-year-old male enrollee has requested reimbursement for air ambulance transport provided on 2/12/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. . The patient was receiving adequate care at the initial location in California.	Upheld	Medical Necessity	Summary Reviewer A 36-year-old male enrollee has requested reimbursement for air ambulance transport provided on 2/12/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. Based on the medical records submitted for review, there is no medical reason for the patients transfer. The patient was receiving adequate care at the initial location in California. The promise of successful weaning off mechanical ventilation does not warrant the risks for transferring a patient such a long distance. In some case, patients are better off on the ventilator. In this case, there is no evidence that this patient, who has been on a ventilator since 2011 was weanable. All told, the air ambulance transport provided on 2/12/14 was not medically necessary for treatment of the 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.	0
A 19-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 8/1/13 through 9/26/13. 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 patient presents with multiple diagnoses including depressive disorder, autism spectrum disorder, attention-deficit/hyperactivity disorder and substance abuse. Almost half of children with these problems had suicide ideation or attempts. The patient had recently been hospitalized due to an overdose of Xanax.	Overturned	Medical Necessity	Summary Reviewer A 19-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 8/1/13 through 9/26/13. 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 that the mental health residential treatment provided from 8/1/13 through 9/26/13 were medically necessary for treatment of the patients medical condition. The documentation submitted for review supports the residential placement. The patient presents with multiple diagnoses including depressive disorder, autism spectrum disorder, attention-deficit/hyperactivity disorder and substance abuse. According to Mayes and colleagues Comorbid psychological problems most highly predictive of ideation or attempts were depression, behavior problems, and teased. Almost half of children with these problems had suicide ideation or attempts. The patient had recently been hospitalized due to an overdose of Xanax. The treatment at issue was medically necessary to assist the patient with handling life stressors in the context of autism spectrum disorder. Thus, the residential mental health services at issue were 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 51-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 5/23/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who reported bilateral breast tenderness.	Overturned	Experimental	Summary Reviewer 3 A 51-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 5/23/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who reported bilateral breast tenderness. 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. There is a lack of support for breast tomosynthesis in patients case. Generally, bilateral breast tenderness is an unlikely presenting symptom for breast cancer. In addition, she did not have particularly dense breasts, and her mammogram was unchanged when compared to a prior mammogram. Breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to prior mammograms. Thus, breast tomosynthesis performed on 5/23/16 was not likely to have been of greater benefit than other available modalities. 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.	1
A 40-year-old female enrollee has requested authorization and coverage for spinal fusion. 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 lateral recess stenosis at L4-5 and severe foraminal stenosis at L5-S1. . This patient presents with persistent worsening low back pain radiating into the left lower extremity to the calf consistent with a left L5 radiculopathy. findings were consistent with imaging evidence of lateral recess stenosis at L4-5 and severe foraminal stenosis at L5-S1. There is radiographic evidence of spondylolisthesis at L4-5 exaggerated in extension and reduced in flexion. The treating provider has planned complete facetectomy and foraminotomy to achieve adequate nerve root decompressi	Overturned	Medical Necessity	Summary Reviewer A 40-year-old female enrollee has requested authorization and coverage for spinal fusion. 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 lateral recess stenosis at L4-5 and severe foraminal stenosis at L5-S1. The physician reviewer found there is sufficient support for the requested services in this patients case. Evidence-based medical guidelines support lumbar fusion in the setting of degenerative spondylolisthesis with symptomatic radiculopathy or spinal stenosis when nonoperative treatment has failed. Lumbar fusion is also supported in the setting of wide decompression with anticipated intraoperative instability. This patient presents with persistent worsening low back pain radiating into the left lower extremity to the calf consistent with a left L5 radiculopathy. Significant functional difficulty is documented in ambulation and activities of daily living. Detailed evidence of a comprehensive nonoperative treatment protocol trial and failure has been submitted. Clinical examination findings were consistent with imaging evidence of lateral recess stenosis at L4-5 and severe foraminal stenosis at L5-S1. There is radiographic evidence of spondylolisthesis at L4-5 exaggerated in extension and reduced in flexion. The treating provider has planned complete facetectomy and foraminotomy to achieve adequate nerve root decompression which would result in temporary intraoperative instability and necessitate fusion. Thus, the requested spinal fusion is medically indicated for the treatment of this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.	1
A 41-year-old female enrollee has requested reimbursement for monitored anesthesia care (MAC) services provided on 2/12/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees risk for colon cancer. this patient has a history of extreme anxiety and panic attacks.	Overturned	Medical Necessity	Summary Reviewer A 41-year-old female enrollee has requested reimbursement for monitored anesthesia care (MAC) services provided on 2/12/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees risk for colon cancer. The physician reviewer found that The American Society of Anesthesiologist (ASA) noted that MAC with sedation may be necessary to improve patient cooperation, decreased movement, and reduce discomfort during endoscopy procedures in patients with significant psychiatric disorders, cognitive dysfunction and movement disorders. The ASA also noted that MAC is necessary for patients in situations of extreme procedure anxiety. The records indicate that this patient has a history of extreme anxiety and panic attacks. Thus, the MAC services were appropriate and medically necessary during the colonoscopy performed on 2/12/15 for evaluation of this patients medical condition. Based on the foregoing discussion, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.	1
The parent of a 16-year-old male insured has requested reimbursement for a laboratory test performed on 2/10/23. The Health Insurer has denied this request indicating that the services at issue were considered investigational for the evaluation of the insureds Chrons disease.	Overturned	Experimental	Summary Reviewer 3 The parent of a 16-year-old male insured has requested reimbursement for a laboratory test performed on 2/10/23. The Health Insurer has denied this request indicating that the services at issue were considered investigational for the evaluation of the insureds Chrons disease. The physician reviewer found that according to Cheifetz and colleagues, When infliximab de- escalation (dose reduction) is considered in patients in remission, proactive TDM both before and after de-escalation should be performed. In this case, the patients Inflectra dosage was reduced. Evaluating Inflectra drug levels and antibody levels both before and after changing dose is the standard of care for this patient. For this reason, the laboratory test performed on 2/10/23 was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy.	0
A 20-year-old female enrollee has requested authorization and coverage for arthroscopy of the knee. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has a history of knee pain. anterior cruciate ligament reconstruction. This patient presents with persistent right knee pain and stiffness nearly three years status post anterior cruciate ligament reconstruction for complete rupture.	Overturned	Medical Necessity	Summary Reviewer A 20-year-old female enrollee has requested authorization and coverage for arthroscopy of the knee. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has a history of knee pain. The physician reviewer found that the peer reviewed literature supports arthroscopy debridement of cyclops lesions, lysis of adhesions and manipulation under anesthesia of the knee to restore full knee extension when loss of full extension and painful stiffness persist, despite aggressive rehabilitation following anterior cruciate ligament reconstruction. This patient presents with persistent right knee pain and stiffness nearly three years status post anterior cruciate ligament reconstruction for complete rupture. The submitted documentation supports the patients loss of full extension. There is documented pain consistent with imaging evidence of synovitis, intercondylar notch scar tissue, and possible cyclops lesion. Evidence of long-term reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. As such, the requested services are medically necessary for treatment of this patients medical condition. Therefore, based on 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
The patient is a 61-year-old male with benign prostatic hyperplasia (BPH) and American Urological Association (AUA) symptom score of 20. The patient underwent UroLift on 10/18/16 to relieve obstructive symptoms. The patient has requested reimbursement for the UroLift procedure provided on 10/18/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational.	Upheld	Experimental	Summary Reviewer 1 The patient is a 61-year-old male with benign prostatic hyperplasia (BPH) and American Urological Association (AUA) symptom score of 20. The patient underwent UroLift on 10/18/16 to relieve obstructive symptoms. The patient has requested reimbursement for the UroLift procedure provided on 10/18/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational. Currently, there is a lack of peer-reviewed medical literature or clinical guidelines that support the utility of UroLift with standard available treatment options. As noted by Chung and Woo, UroLift appears to be a well tolerated and effective minimally invasive treatment for lower urinary tract symptoms due to BPH in men who wish to preserve sexual function or who are not suitable for invasive surgery. Further studies will confirm the currently mixed results regarding intraprostatic botulinum toxin or ethanol injections. Thus, additional investigation is appropriate to confirm these initial results. For these reasons, the UroLift procedure provided on 10/18/16 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, the service 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 50-year-old male has requested reimbursement for Anser IFX testing performed on 4/15/15. 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 3 A 50-year-old male has requested reimbursement for Anser IFX testing performed on 4/15/15. 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 the Anser IFX test was ordered to direct the use of Remicade in this patient with Crohns disease. However, the use of Anser IFX to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. Based on the clinical literature, the Anser IFX testing performed on 4/15/15 was not likely to be more beneficial for treatment of the patients medical condition than standard management. 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.	0
A 64-year-old female enrollee has requested placement of permanent sacral nerve stimulator performed on 12/09/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees fecal incontinence.	Overturned	Experimental	Summary Reviewer 2 A 64-year-old female enrollee has requested placement of permanent sacral nerve stimulator performed on 12/09/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees fecal incontinence. The physician reviewer found there is sufficient support for the services at issue in this patients case. According to the American Society of Colon and Rectal Surgeons guideline for the treatment of fecal incontinence, sacral neuromodulation may be considered as a first-line surgical option for incontinent patients with and without sphincter defects. The treatment consistently demonstrates reduction in frequency of incontinence episodes in studies. In this patients case, the permanent sacral nerve stimulator provided on 12/09/14 was likely to have been of greater benefit 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.	1
patient is a 54-year-old female with a history of non-allergic rhinitis, previously diagnosed nasal septal deviation, asthma and recurrent acute sinusitis. The patient has requested authorization and coverage for computed tomography (CT) scan of the sinuses. This patient also has progressive sinus disease that has affected her ability to smell and does	Overturned	Medical Necessity	Summary Reviewer The patient is a 54-year-old female with a history of non-allergic rhinitis, previously diagnosed nasal septal deviation, asthma and recurrent acute sinusitis. The patient has requested authorization and coverage for computed tomography (CT) scan of the sinuses. The physician reviewer found that the current medical literature supports the requested CT scan of the sinuses in this case. The American Academy of Allergy, Asthma and Immunology (AAAAI) Practice Parameters for the management of sinusitis discusses that if a patient fails antibiotics and other adjunctive measures such as inflammation control with systemic steroids, nasal sprays (azelastine and fluticasone) and Singulair, a sinus CT would be indicated. This patient also has progressive sinus disease that has affected her ability to smell and does not have positive skin testing to indicate that allergies would be the main driving factor for her recurrent inflammation. She also does have documented septal deviation which could contribute to her rhinitis and sinusitis. In addition, the Rhinitis 2020 AAAAI practice parameter update does consider symptoms including facial pain, pressure, decreased sense of smell and post-nasal drainage to be an indication for sinus CT. Therefore, the requested CT scan of the sinuses is medically necessary for the evaluation of this patient.	1
A 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 1/19/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.	Overturned	Experimental	Summary Reviewer 2 A 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 1/19/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the breast tomosynthesis performed on 1/19/16 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two dimensional (2D) and three dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the support in the medical literature, the use of breast tomosynthesis 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 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
A 57-year-old male enrollee has requested reimbursement for automated nerve conduction testing during anterior cervical discectomy and fusion performed on 10/20/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. during multiple level anterior cervical discectomy and fusion in the presence of myelopathy.	Overturned	Medical Necessity	Summary Reviewer A 57-year-old male enrollee has requested reimbursement for automated nerve conduction testing during anterior cervical discectomy and fusion performed on 10/20/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the patient underwent intraoperative neurophysiological monitoring during multiple level anterior cervical discectomy and fusion in the presence of myelopathy. Intraoperative neurophysiological monitoring during surgery is recommended when such procedures have a risk of significant complications that can be detected and prevented through use of neurophysiological monitoring. Intraoperative monitoring of somatosensory evoked potentials and transcranial electrical motor evoked potentials in procedures that involve the spinal cord itself can predict adverse surgical outcomes in complex cases. However, the evidence-based guidelines do not recommend intraoperative electromyography (EMG) and nerve conduction velocity monitoring on peripheral nerves during cervical spine surgery. An abnormal EMG response during the surgical procedure may or may not be associated with a clinically significant injury (Resnick, et al). Therefore, intraoperative electromyography is not recommended. In sum, intraoperative EMG and nerve conduction velocity monitoring on peripheral nerves during surgery is not recommended. In sum, the somatosensory and motor evoked potentials were medically necessary; however, the intraoperative electromyography and neuromuscular junction testing has not been substantiated. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.	1
A 60-year-old female enrollee has requested authorization and coverage for bronchoscopic thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees moderate to severe persistent asthma. This patient has undergone a thorough evaluation and is on an aggressive regimen. However, her symptoms have persisted despite her current medical therapy and she has continuously required systemic steroids.	Overturned	Medical Necessity	Summary Reviewer A 60-year-old female enrollee has requested authorization and coverage for bronchoscopic thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees moderate to severe persistent asthma. The physician reviewer found that currently, the three initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed. Cox and colleagues reported that patients with moderate to severe asthma demonstrated improved control at one-year follow-up following treatment with bronchial thermoplasty. Further, Pavord and colleagues found short-term worsening in symptoms, but evidence of improved long-term control of asthma with the procedure. Finally, the Castro and colleagues compared bronchial thermoplasty with a sham procedure and followed the patients for one year. The authors noted that the thermoplasty group had fewer exacerbations and improved quality of life when compared to the sham group. Overall, the data supports the short- and long-term benefits of bronchial thermoplasty for well selected patients. This patient has undergone a thorough evaluation and is on an aggressive regimen. However, her symptoms have persisted despite her current medical therapy and she has continuously required systemic steroids. Given these findings, the requested bronchoscopic thermoplasty is supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.	1
A 65-year-old male enrollee has requested authorization and coverage for PET (CPT code 78813) scan. The Health Insurer has denied this request indicating that the requested testing considered investigational for evaluation of the enrollees prostate cancer.	Overturned	Experimental	Summary Reviewer 3 A 65-year-old male enrollee has requested authorization and coverage for PET (CPT code 78813) scan. The Health Insurer has denied this request indicating that the requested testing considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that a recent trial assessed the impact of PET (Axumin) scans on patients with a biochemical recurrence. It found that 61.2% of patients had a change in management as a result of the scan and the trial was stopped early. Of the changes, 40% required a change in radiation fields, and 35% underwent systemic therapy instead of radiotherapy (ASCO GU 2018). Recent medical literature have come to similar conclusions that PET scans can affect treatment after a prostatectomy (Wallitt, et al; Jani, et al). As such, PET (CPT code 78813) scan is likely to be of greater benefit when compared to the available conventional modalities for the management of this patients medical condition. Therefore, for the reasons stated above, the requested services are 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 68-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/03/18 and 10/16/18. The Health Insurer has denied this request and reported that the service at issue were not medically necessary for the evaluation of the enrollees medical condition.	Upheld	Medical Necessity	Summary Reviewer A 68-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/03/18 and 10/16/18. The Health Insurer has denied this request and reported that the service at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had several early stage melanomas. 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. 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. Therefore, DecisionDx-Melanoma testing provided on 10/03/18 and 10/16/18 was not medically necessary for the evaluation of this patient.	0
A 48-year-old female enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 4/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer.	Overturned	Experimental	Summary Reviewer 1 A 48-year-old female enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 4/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found there is sufficient support for the services at issue in this clinical setting. It has been established that adjuvant chemotherapy is of benefit to patients with stage III (node positive) colon cancer. It is much more controversial as to its value in stage II colon cancer, as in this patients case. Most oncologists have made this decision based on specific pathologic features, such as a poorly differentiated histology, lymphovascular invasion, or presentation with obstruction or perforation. Another approach is with the use of genetic panels. The Oncotype DX Colon Cancer Assay is a 12-gene panel that predicts the risk of recurrence of the cancer in both stage II and III colon cancer. This assay appears to predict the risk of recurrence with accuracy beyond what could be predicted from these usual pathologic features. The medical evidence supports the use of Oncotype DX Colon Cancer Assay in assessing the potential value of adjuvant chemotherapy. Therefore, Oncotype DX Colon Cancer Assay performed on 4/28/16 was likely to have been more efficacious 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.	1
A 48-year-old female enrollee has requested reimbursement for genetic testing performed on 5/25/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees breast cancer.	Upheld	Medical Necessity	Summary Reviewer A 48-year-old female enrollee has requested reimbursement for genetic testing performed on 5/25/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees breast cancer. The physician reviewer found that understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise, but is not yet ready for routine clinical use. Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of NGS, such as with FoundationOne testing, continues to be the subject of ongoing clinical trials, and use outside of a clinical trial at this time is not reasonable or medically necessary. In addition, this patient still has treatment options available to her, such as TDM-1. Thus, genetic testing performed on 5/25/17 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 62-year-old female enrollee has requested reimbursement for FoundationOne CDx test performed on 12/31/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition.	Overturned	Experimental	Summary Reviewer 3 A 62-year-old female enrollee has requested reimbursement for FoundationOne CDx test performed on 12/31/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition. The physician reviewer found that the The therapy of advanced NSCLC has been revolutionized by the finding of EGFR mutations in certain adenocarcinomas. Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of NSCLC has significantly expanded in recent years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. It is generally accepted that the panel of mutations that was analyzed in the patient in question is for mutually exclusive somatic driver mutations. Patients on targeted therapy may develop resistance to erlotinib and this too may be appreciated at the genetic level by recognition of new mutations or amplifications in parallel signal transduction pathways. BRAF mutations may suggest alternative targeted therapies that may be better than those selected empirically. There is sufficient support for the services at issue in this clinical setting. Therefore, FoundationOne CDx test performed on 12/31/19 was likely to have been more beneficial than other available standard therapy.	0
A 60-year-old male enrollee has requested reimbursement for CPT 81529, which is an oncology (cutaneous melanoma, mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and three housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk including likelihood of sentinel lymph node metastasis, on 3/8/22. The Health Insurer has denied this request and reported that the service at issue was investigational for the evaluation of the enrollees melanoma.	Upheld	Experimental	Summary Reviewer 3 A 60-year-old male enrollee has requested reimbursement for CPT 81529, which is an oncology (cutaneous melanoma, mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and three housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk including likelihood of sentinel lymph node metastasis, on 3/8/22. The Health Insurer has denied this request and reported that the service at issue was investigational for the evaluation of the enrollees melanoma. The physician reviewer found that the American Academy of Dermatologys clinical guidelines for melanoma note that routine molecular testing, including GEP, for prognostication is discouraged until better use criteria are defined. The guidelines further note that the application of molecular information for clinical management, such as informing on sentinel lymph node eligibility, follow-up, and/or therapeutic choices, is not recommended outside of a clinical study or trial. The NCCN guidelines on cutaneous melanoma note that the use of GEP testing according to specific American Joint Committee on Cancer (AJCC)-8 melanoma staging, before or after sentinel lymph node biopsy, requires further prospective investigation in large, contemporary data sets of unselected patients, and that prognostic GEP testing to differentiate melanomas at low versus high risk for metastasis should not replace pathologic staging procedures. The NCCN further notes that there is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive results, and that GEP testing should not guide clinical decision-making in this subgroup. Therefore, CPT 81529, which is an oncology (cutaneous melanoma, mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and three housekeeping), utilizing formalin- fixed paraffin-embedded tissue, algorithm reported as recurrence risk including likelihood of sentinel lymph node metastasis, on 3/8/22, was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.	1
A 51-year-old male enrollee has requested reimbursement for DecisionDX testing provided on 10/6/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.	Overturned	Experimental	Summary Reviewer 1 A 51-year-old male enrollee has requested reimbursement for DecisionDX testing provided on 10/6/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma. The physician reviewer found choroidal melanoma is a relatively rare tumor which has consequences on both vision and lifespan. Metastatic disease prediction has been difficult and little data has been available to providers to educate the patient and to aid in the type and frequency of tests to order to follow the disease. With the DecisionDX assay the provider has a tool at their disposal to help predict the likelihood of metastatic disease and accordingly prescribe adjuvant therapy. The DecisionDX also helps provide a feasible schedule for the frequency of metastatic disease testing via laboratory and imaging studies. Given this support, the DecisionDX testing provided on 10/6/14 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, I have determined 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 61-year-old male with a history of hypothyroidism on escalating doses of levothyroxine. The patient has requested reimbursement for the ultrasound of the soft tissues of head and neck performed on 1/12/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient.	Upheld	Medical Necessity	Summary Reviewer The patient is a 61-year-old male with a history of hypothyroidism on escalating doses of levothyroxine. The patient has requested reimbursement for the ultrasound of the soft tissues of head and neck performed on 1/12/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that Hypothyroidism affects up to 5% of the general population, with a further estimated 5% being undiagnosed. Hypothyroidism is diagnosed biochemically, being overt primary hypothyroidism defined as serum thyroid stimulating hormone (TSH) concentrations above and thyroxine concentrations below the normal reference range. Although studies have demonstrated that patients diagnosed with hyperthyroidism, thyroiditis, goiter, and adenoma had significantly elevated risks of differentiated thyroid cancer, there does not appear to be an association between a history of hypothyroidism and risk of thyroid cancer. Thyroid ultrasonography is not indicated as part of routine workup of hypothyroidism. Therefore, the ultrasound of the soft tissues of head and neck performed on 1/12/21 was not medically necessary for the evaluation of this patient.	1
The patient is a five-year-old male who has been diagnosed with disorder of dysregulated anger and aggression of early childhood, combined, proactive and reactive aggression. The patientas parent has requested reimbursement for intensive outpatient mental health treatment for children and adolescents provided from 7/15/19 through 7/31/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The patient had a significant risk of harm, due to impulsivity, self-harm, and aggression. The patient had moderate functional impairment, due to conflict with parents and other adults as well as peers, and recent expulsion from school. Gains were The patient had a mildly stressful environment, due to expulsion from school.	Overturned	Medical Necessity	Summary Reviewer The patient is a five-year-old male who has been diagnosed with disorder of dysregulated anger and aggression of early childhood, combined, proactive and reactive aggression. The patientas parent has requested reimbursement for intensive outpatient mental health treatment for children and adolescents provided from 7/15/19 through 7/31/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. 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 3. The patient had a significant risk of harm, due to impulsivity, self-harm, and aggression. With regard to functional status, the records support a score of 3. The patient had moderate functional impairment, due to conflict with parents and other adults as well as peers, and recent expulsion from school. Gains were made in the context of a structured setting. In terms of comorbidity, the records support a score of 1. There were no developmental or medical issues. With regard to level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment, due to expulsion from school. In terms of environmental support, the records support a score of 2 due to his parentsa attempts to participate in treatment, with some struggles to manage the patientas behavior and medications at home. In terms of resiliency and treatment history, the records support a score of 4. The records indicate poor resiliency and/or response to treatment, due to a lack of response to previous intensive treatment, and his current turmoil and difficulty making progress toward developmentally appropriate behaviors. With regard to treatment and acceptance of the parents, the records support a score of 2 due to their participation in treatment. Thus, the patient had a total score of 17. This recommended level of care is high-intensity community-based services. An intensive outpatient program, such as the one the patient was attending, is consistent with this level of care. Furthermore, a program specializing in young children was needed for the patient. Therefore, intensive outpatient mental health treatment for children and adolescents provided from 7/15/19 through 7/31/19 was medically necessary for the treatment of this patient.	1
A 58-year-old female enrollee has requested reimbursement for MammaPrint testing performed on 1/21/14. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the evaluation of the enrollees breast cancer. In this case, the patient was provided with adjuvant chemotherapy based on her high risk MammaPrint profile.	Upheld	Experimental	Summary Reviewer 3 A 58-year-old female enrollee has requested reimbursement for MammaPrint testing performed on 1/21/14. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the evaluation of the enrollees breast cancer. The physician reviewer found there are several established biomarkers that are prognostically valuable in breast cancer. These include the presence of estrogen or progesterone receptors, HER2 amplification, as well as proliferative index, and histologic grade. Newer technologies such as gene expression such as the MammaPrint may also classify tumors to basal-like or luminal-type of disease. MammaPrint is U.S. Food and Drug Administration (FDA) approved and has been validated in different clinical trials. In this case, the patient was provided with adjuvant chemotherapy based on her high risk MammaPrint profile. Based on available medical evidence and medical literature, MammaPrint was likely to be more beneficial for evaluation of the patients medical condition than other modalities. 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 36-year-old female enrollee has requested reimbursement for Botox injections received on 10/14/14. The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. the patient has chronic migraine. In addition, the patient has failed at least two classes of preventive agents.	Overturned	Experimental	Summary Reviewer 1 A 36-year-old female enrollee has requested reimbursement for Botox injections received on 10/14/14. 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 review of the submitted documentation and relevant literature supports the use of Botox injections in this clinical setting. The documentation submitted for review documents the patient has chronic migraine. In addition, the patient has failed at least two classes of preventive agents. Botox is standard therapy for treatment of chronic migraine, and has been shown to be as effective or more effective, than medications available to treat chronic migraine. In addition, Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic migraine. For the reasons provided, the Botox injections at issue were 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 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.	1
A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/17/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition.	Upheld	Experimental	Summary Reviewer 3 A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/17/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas 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 very novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Therefore, DecisionDx-Melanoma testing performed on 5/17/19 was not likely to have been more beneficial than other available standard therapy.	0
A 61-year-old female enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. She has moderate obstructive sleep apnea. The documentation notes that the patient is intolerant to continuous positive airway pressure therapy.	Overturned	Experimental	Summary Reviewer 3 A 61-year-old female enrollee has requested authorization and coverage for 64568 and 0466T. 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 there is a lack of support for the requested services in this patients case. She has moderate obstructive sleep apnea. The documentation notes that the patient is intolerant to continuous positive airway pressure therapy. The records do not clearly establish that the patient is not a candidate for oral appliance therapy. Mild to moderate obstructive sleep apnea has been shown to be responsive to oral appliance therapy. Thus, 64568 and 0466T are not likely to be more beneficial than other treatment options.	1
A 44-year-old female enrollee has requested authorization and coverage for the Intracept procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. involved 17 patients who were treated for refractory chronic low back pain.	Overturned	Experimental	Summary Reviewer 3 A 44-year-old female enrollee has requested authorization and coverage for the Intracept procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a sparse amount of published clinical data to support the use of this treatment modality. An industry sponsored trial by Becker and colleagues involved 17 patients who were treated for refractory chronic low back pain. The authors concluded, aAblation of the basivertebral nerve for the treatment of chronic lumbar back pain significantly improves patientsa self-reported outcome early in the follow-up period; the improvement persisted throughout the one-year study period.a Fischgrund and colleagues performed a multicenter randomized control trial involving 225 patients with refractory low back pain. The authors noted, aPatients treated with radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited significantly greater improvement in Oswestry Disability Index (ODI) at three months and a higher responder rate than sham treated controls.a While there is a small amount of supporting data which suggests some short-term patient reported outcomes with the Intracept procedure, some of this data is industry sponsored. The single randomized controlled trial demonstrates some potential short-term benefit, but is lacking long-term efficacy and safety data. Clinical conclusions on this procedureas safety and efficacy require longer-term safety and efficacy data prior to accepting it as standard of care. Thus, the requested Intracept procedure is not likely to be more beneficial than any available standard therapy.	1
An 18-year-old female enrollee has requested reimbursement for mental health residential treatment center (RTC) services provided from 2/4/15 through 4/24/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bipolar disorder, parent-child relational problem, and cannabis abuse. The patient did not have any suicidal or homicidal ideations, there was no evidence of psychosis, and she had no self-injurious impulses during the course of treatment documented.	Upheld	Medical Necessity	Summary Reviewer An 18-year-old female enrollee has requested reimbursement for mental health residential treatment center (RTC) services provided from 2/4/15 through 4/24/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bipolar disorder, parent-child relational problem, and cannabis abuse. The physician reviewer found that based on the records provided for review, the criteria for RTC services from 2/4/15 through 4/24/15 have not been met. The patient did not have any suicidal or homicidal ideations, there was no evidence of psychosis, and she had no self-injurious impulses during the course of treatment documented. Additionally, no medication changes were made during the course of admission that required 24-hour supervision. The records suggest the patient could have been treated safely and effectively in a less intrusive, less invasive level of care such as outpatient medication management and outpatient therapy during this period of time. Accordingly, the RTC services provided from 2/4/15 through 4/24/15 were not medically necessary. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.	1
The patient is a 19-year-old female who has been recognized to have a number of inherited disorders, including intellectual disability, multiple congenital anomalies including, coarctation of the aorta and small left ventricles unbalanced atrioventricular canal defect and short stature. The patient underwent genetic testing in order to obtain additional information and to best guide medical management of her care. The patient has requested reimbursement for FirstStepDX Plus test rendered on 4/14/17. The Health Insurer has denied the request for reimbursement. Per the Health Insurer, the services at issue were investigational. in April 2017. The provider ordered testing to gather additional information that could affect the care and treatment of this patient.	Overturned	Experimental	Summary Reviewer 3 The patient is a 19-year-old female who has been recognized to have a number of inherited disorders, including intellectual disability, multiple congenital anomalies including, coarctation of the aorta and small left ventricles unbalanced atrioventricular canal defect and short stature. The patient underwent genetic testing in order to obtain additional information and to best guide medical management of her care. The patient has requested reimbursement for FirstStepDX Plus test rendered on 4/14/17. The Health Insurer has denied the request for reimbursement. Per the Health Insurer, the services at issue were investigational. There is support in the medical literature for the efficacy of the tests performed in April 2017. The provider ordered testing to gather additional information that could affect the care and treatment of this patient. The records show that the patients clinical presentation is not specific to a well delineated syndrome and she has two or more major malformations. As such, targeted genetic testing is relevant as a rationale pursuit of information that could potentially alter treatment services. All told, the FirstStepDX Plus test rendered on 4/14/17 was likely to have been more efficacious for evaluating this patients medical condition when compared to other available standard options. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.	1
A 45-year-old male enrollee has requested reimbursement for ipilimumab and nivolumab provided on 6/11/19, 7/02/19, 7/23/19 and 8/13/19. The Health Insurer has denied this request and reported that the medications at issue were investigational for the treatment of the enrollees medical condition.	Overturned	Experimental	Summary Reviewer 3 A 45-year-old male enrollee has requested reimbursement for ipilimumab and nivolumab provided on 6/11/19, 7/02/19, 7/23/19 and 8/13/19. The Health Insurer has denied this request and reported that the medications at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the medications at issue in this clinical setting. In patients with widespread metastatic renal cell cancer, this combination of immunotherapy drugs is superior to more standard therapy, and is currently the recommended treatment. The medullary variant is a rare variant, and there is less data concerning this type. Nonetheless, this combination was likely to have been more effective than other treatment alternatives. Thus, ipilimumab and nivolumab provided on 6/11/19, 7/02/19, 7/23/19 and 8/13/19 were likely to have been more beneficial than other available treatment options.	1
The patient is a 55-year-old female with a history of rheumatoid arthritis. On 8/18/16, she was being treated with methotrexate, prednisone and Xeljanz. Per the records, Xeljanz had improved her symptoms, but she was having more frequent outbreaks of herpes. During the past month, she had experienced pain in her right elbow, worse back pain, left ankle pain/stiffness and weight gain. The records noted that the patient has responded to Remicade in the past, although this was discontinued due to cost. The patients provider recommended retrying Remicade, but the provider reported concerns given the long period of abstinence. The provider recommended Prometheus Anser IFX testing. The Health Insurer has denied reimbursement for Prometheus Anser IFX testing performed on 8/19/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient.	Upheld	Experimental	Summary Reviewer 1 The patient is a 55-year-old female with a history of rheumatoid arthritis. On 8/18/16, she was being treated with methotrexate, prednisone and Xeljanz. Per the records, Xeljanz had improved her symptoms, but she was having more frequent outbreaks of herpes. During the past month, she had experienced pain in her right elbow, worse back pain, left ankle pain/stiffness and weight gain. The records noted that the patient has responded to Remicade in the past, although this was discontinued due to cost. The patients provider recommended retrying Remicade, but the provider reported concerns given the long period of abstinence. The provider recommended Prometheus Anser IFX testing. The Health Insurer has denied reimbursement for Prometheus Anser IFX testing performed on 8/19/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient. The anti-tumor necrosis factor agents have been noted to be associated with an increasing amount of autoantibodies resulting in an increased risk of infusion reactions, a reduced response to medications, and the need for increasing dose adjustments. Up to about 50% of patients treated with infliximab develop these antibodies, and those patients with high antibodies have been found to have a higher risk of infusion reactions. In this patients case, based on the records from 8/18/16, there was evidence of active rheumatoid arthritis and intolerance of Xeljanz. She has tolerated Remicade in the past, with no reactions, and other anti-tumor necrosis factor agents were stopped due to ineffectiveness or cost. There is a lack of evidence to support that Remicade would be ineffective or possibly harmful. Remicade was stopped in the past due to cost, not medical issues. At this time, the role of this testing is still being determined. As such, the medical records and the current medical literature fail to support that Prometheus Anser IFX testing performed on 8/19/16 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 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 25-year-old female has requested authorization and coverage for intravenous ceftriaxone. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. This patient was diagnosed with neuroborreliosis per the submitted records. . This patient has been treated with intravenous ceftriaxone for 28 days.	Upheld	Experimental	Summary Reviewer 2 A 25-year-old female has requested authorization and coverage for intravenous ceftriaxone. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the medical evidence does not support the requested medication in this clinical setting. This patient was diagnosed with neuroborreliosis per the submitted records. Current Lyme disease guidelines and data indicated that ceftriaxone is recommended for 14 to 21 days. This patient has been treated with intravenous ceftriaxone for 28 days. In addition, doxycycline has been shown to be non-inferior to ceftriaxone in some studies. Moreover, atovaquone and azithromycin are standard treatment regimens for Babesia. For those reasons, the requested intravenous ceftriaxone is not likely to be of greater benefit than other available treatment alternatives. Based upon the information set forth above, the requested medication 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.	1
An 81-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 7/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition.	Upheld	Experimental	Summary Reviewer 1 An 81-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 7/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that he National Comprehensive Cancer Network (NCCN) guidelines define the low-risk group as patients with clinical stage T1 to T2a, Grade Group 1, and serum prostate specific antigen (PSA) level less than 10 ng/mL. If the patientas life expectancy is 10 years or more, initial treatment options include: 1) active surveillance (preferred); 2) external beam radiation therapy or brachytherapy; or 3) radical prostatectomy. Molecular tumor testing can be considered for these men for prognostic information independent of NCCN risk groups. Recommendations per the NCCN guidelines support coverage post-biopsy for NCCN very-low-, low-risk, and favorable intermediate-risk prostate cancer in patients with at least 10 years life expectancy who have not received treatment for prostate cancer and are candidates for active surveillance or definitive therapy. The records indicate that this patient underwent Oncotype DX Prostate testing in 2019 as well as on 7/23/20. There is a lack of support for the services performed on 7/23/20, as Oncotype DX Prostate testing is intended for use at initial diagnosis. Therefore, Oncotype DX Prostate testing performed on 7/23/20 was not likely to have been more beneficial than other methods of evaluating this patient.	1
A 64-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma gene expression profile testing performed on 7/23/18. 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.	Upheld	Medical Necessity	Summary Reviewer A 64-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma gene expression profile testing performed on 7/23/18. 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 the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had 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. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. Therefore, DecisionDx-Melanoma gene expression profile testing performed on 7/23/18 was not medically necessary for the evaluation of this patient.	0
A 65-year-old male enrollee has requested reimbursement for polymerase chain reaction (PCR) testing on 8/10/21. The Health Insurer has denied this request and reported that the service at issue was investigational for the evaluation of the enrollees severe diarrhea.	Upheld	Experimental	Summary Reviewer 2 A 65-year-old male enrollee has requested reimbursement for polymerase chain reaction (PCR) testing on 8/10/21. The Health Insurer has denied this request and reported that the service at issue was investigational for the evaluation of the enrollees severe diarrhea. The physician reviewer found that in the setting of acute diarrhea in a non-toxic, healthy patient, standard therapy consists of supportive care. Many of the organisms tested for, such as norovirus, cause self-limited disease and have no treatment. Others cause self-limited disease and can be treated with antibiotics, although antibiotics tend to delay clearance of the organism and may cause immune-mediated side effects such as hemolytic uremic syndrome. Additionally, many of the organisms tested for, such as entamoeba histolytica, are incredibly rare in North Americans eating a normal diet such that testing for them does not make sense. In this clinical setting, the PCR testing at issue, which involved testing for numerous gastrointestinal pathogens, was not likely to be more beneficial than standard testing using routine cultures for pathogens including E. coli subtype, or a PCR or enzyme immunoassay (EIA) test limited to determine the presence of Clostridioides difficile. Therefore, PCR testing on 8/10/21 was not likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy.	0
The parent of a nine-year-old female enrollee has requested reimbursement and prospective authorization and coverage for 20 hours per week of applied behavioral analysis (ABA) therapy provided from 9/28/17 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 autism spectrum disorder.	Upheld	Medical Necessity	Summary Reviewer The parent of a nine-year-old female enrollee has requested reimbursement and prospective authorization and coverage for 20 hours per week of applied behavioral analysis (ABA) therapy provided from 9/28/17 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 autism spectrum disorder. The physician reviewer found that the request for 20 hours per week of ABA therapy provided from 9/28/17 forward was not and is not medically necessary for treatment of the patients autism spectrum disorder. According to the documentation submitted for review, the patient is documented as making progress with her goals. The Health Insurer authorized 16 hours per week of ABA therapy is medically appropriate and adequate in this clinical setting. In sum, there is a lack of clinical documentation supporting the request for 20 hours per week of direct ABA services for treatment of the patients autism spectrum disorder. 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 overturned.	0
A 27-year-old male enrollee has requested reimbursement for acute inpatient mental health treatment for adults provided from 4/25/16 through 6/5/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. On 4/24/16, the test results from the psychosis work-up had not yet returned. The patient remained guarded and isolative. He had no insight regarding his mental illness. Further, he was refusing psychotropic medication. was being forged, the patient continued with the diagnostic work-up. Aside from a slightly elevated cholesterol level, his laboratory studies were unremarkable. On 5/4/16, the electroencephalogram finding was normal. On 5/6/16, the neuropsychology report was published while the magnetic resonance imaging (MRI) of the brain was normal. On 5/10/16, the patient elected to start an antipsychotic medication. On 5/13/16, the patient was described as reserved and polite and noted to have no side effect from the medication. On 5/17/16, the patient was slowly feeling better. On 5/19/16, the patient agreed to step-down to a	Overturned	Medical Necessity	Summary Reviewer A 27-year-old male enrollee has requested reimbursement for acute inpatient mental health treatment for adults provided from 4/25/16 through 6/5/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the clinical record does not support the medical necessity of service delivery at the acute inpatient level of care as of 5/20/16. On 4/24/16, the test results from the psychosis work-up had not yet returned. The patient remained guarded and isolative. He had no insight regarding his mental illness. Further, he was refusing psychotropic medication. The treatment team did provide thoughtful patient-centric care at a slow-pace to help build the rapport and trust necessary for meaningful therapeutic gains. For example, on 4/27/16, the psychologist did not confront the patients denial, rather the concepts of self-perception and idealism were introduced. As the therapeutic path was being forged, the patient continued with the diagnostic work-up. Aside from a slightly elevated cholesterol level, his laboratory studies were unremarkable. On 5/4/16, the electroencephalogram finding was normal. On 5/6/16, the neuropsychology report was published while the magnetic resonance imaging (MRI) of the brain was normal. On 5/10/16, the patient elected to start an antipsychotic medication. On 5/13/16, the patient was described as reserved and polite and noted to have no side effect from the medication. On 5/17/16, the patient was slowly feeling better. On 5/19/16, the patient agreed to step-down to a less restrictive setting and residential placement was recommended by the psychiatrist. In sum, the admission facilitated the completion of a thorough diagnostic assessment and improved the patients clinical condition. During the course of the admission, the patient had not voiced any new complaints or expressed any suicidal ideation, homicidal ideation or aggressive behavior. He was illogical at times, but neither disruptive nor disrespectful. Based on his past behaviors and the severity of his illness, a structured and supervised setting remained indicated to consolidate the therapeutic gains, but there was no indication that residential placement would have been unsafe or inadequate as of 5/20/16. Thus, the services at the acute inpatient level of care were medically necessary from 4/25/16 through 5/19/16, but not thereafter. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.	1
A 23-year-old female enrollee has requested authorization and coverage for FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis. The Health Insurer has denied this request indicating that the requested services are investigational for the evaluation of the enrollees medical condition.	Overturned	Experimental	Summary Reviewer 2 A 23-year-old female enrollee has requested authorization and coverage for FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis. The Health Insurer has denied this request indicating that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting. Chromosomal microarray testing is an appropriate first-line test for patients with non-syndromic developmental delay/intellectual disability, as well as patients with autism spectrum disorders. There are clear management implications that chromosomal microarray testing has provided for patients. In sum, FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis is likely to be of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the requested services are 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 22-year-old male with a history of idiopathic scoliosis. He has had extensive chiropractic care from 10/13/15 through 7/4/16 for at least 36 visits. His diagnoses are cervical and thoracic sprain, rib sprain, and muscle spasm. His treatment includes chiropractic manipulation, traction, and electrical stimulation, as well as abdominal and low back exercises. Overall, his condition was unchanged and his pain was consistently at 2/10. The patient has requested reimbursement for the chiropractic services provided from 6/13/16 through 8/13/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. The patient has a stable condition that shows no sign of improvement even with continuous extensive care.	Upheld	Medical Necessity	Summary Reviewer The patient is a 22-year-old male with a history of idiopathic scoliosis. He has had extensive chiropractic care from 10/13/15 through 7/4/16 for at least 36 visits. His diagnoses are cervical and thoracic sprain, rib sprain, and muscle spasm. His treatment includes chiropractic manipulation, traction, and electrical stimulation, as well as abdominal and low back exercises. Overall, his condition was unchanged and his pain was consistently at 2/10. The patient has requested reimbursement for the chiropractic services provided from 6/13/16 through 8/13/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. The patient has a stable condition that shows no sign of improvement even with continuous extensive care. This is considered maintenance therapy and chiropractic is not superior to alternative forms of standard treatment. There is also no evidence that chiropractic care is useful in the treatment of idiopathic scoliosis. Therefore, the chiropractic treatments provided from 6/13/16 through 8/13/16 were not medically necessary. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.	1