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A 39-year-old male enrollee has requested authorization and coverage for Stelara (ustekinumab). The Health Insurer has denied this request indicating that the requested medication is investigational for treatment of the enrollees medical condition.
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Overturned
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Experimental
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Summary Reviewer 1
A 39-year-old male enrollee has requested authorization and coverage for Stelara (ustekinumab). The Health Insurer has denied this request indicating that the requested medication is investigational for treatment of the enrollees medical condition. The physician reviewer found that the advent of anti-tumor necrosis factor (TNF) therapy has been a major advance in the medical management of Crohns disease. However, a significant proportion of patients with Crohns disease do not respond adequately to treatment with these agents. Primary and secondary nonresponse to anti-TNF therapy represents a common clinical challenge, and highlights the need for the development of additional medication options for Crohns disease. Ustekinumab is a fully human immunoglobulin G1 monoclonal antibody, which blocks activity of IL-12 and IL-23 through binding the p40 subunit. Relative to the use of ustekinumab in Crohns disease, Sandborn and colleagues demonstrated in a randomized, placebo-controlled study of 526 subjects that Patients with moderate-to-severe Crohns disease that was resistant to TNF antagonists had an increased rate of response to induction with ustekinumab, as compared with placebo. Patients with an initial response to ustekinumab had significantly increased rates of response and remission with ustekinumab as maintenance therapy. Furthermore, Kopylov and colleagues cohort of 38 patients with severe anti-TNF resistant Crohns disease, an initial clinical response to subcutaneous ustekinumab was observed in 73.7% of the patients. In addition, the initial response was successfully maintained in the majority of patients for up to 12 months. Finally, Stelara was first approved by the U.S. Food and Drug Administration (FDA) for the treatment of moderate to severe plaque psoriasis in 2009, and later approved for the treatment of active psoriatic arthritis in 2013. The drug holds considerable promise in non-pregnant Crohns disease patients, and appears to be one of the remaining few treatment options available to the patient at this time. Given the above, Stelara is likely to be more beneficial for treatment of the patients Crohns disease than 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 |
The patient is a 54-year-old male who has been diagnosed with alcohol use disorder, elevated liver function testing, atrial fibrillation, hypertension and rheumatoid arthritis. The patient has requested reimbursement for substance abuse residential treatment from 8/01/19 through 8/04/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient.
acute intoxication/withdrawal potential, the patient was drinking heavily and reported feeling withdrawal symptoms. In terms of dimension 2, biomedical conditions and complications, the patient was on blood thinners, making potential falls while intoxicated fatal.
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Overturned
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Medical Necessity
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Summary Reviewer
The patient is a 54-year-old male who has been diagnosed with alcohol use disorder, elevated liver function testing, atrial fibrillation, hypertension and rheumatoid arthritis. The patient has requested reimbursement for substance abuse residential treatment from 8/01/19 through 8/04/19. 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 per American Society of Addiction Medicine criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. With regards to dimension 1, acute intoxication/withdrawal potential, the patient was drinking heavily and reported feeling withdrawal symptoms. In terms of dimension 2, biomedical conditions and complications, the patient was on blood thinners, making potential falls while intoxicated fatal. With regards to dimension 3, emotional, behavioral or cognitive conditions, the patient had anxiety symptoms. In terms of dimension 4, readiness to change, the patient was willing to change but was ambivalent. With regards to dimension 5, relapse, continued use or continued problem potential, the patient had a long history of use without long periods of sobriety. In terms of dimension 6, recovery environment, the patients environment was supportive but lacked structure. Given the severity of the patients illness, residential treatment was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patients illness. Therefore, substance abuse residential treatment from 8/01/19 through 8/04/19 was medically necessary for the treatment of this patient.
| 1 |
A 22-year-old male enrollee has requested reimbursement for substance use outpatient services provided from 10/25/16 through 11/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.
From 10/25/16 through 11/10/16, the patient was treated using EMDR therapy.
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Overturned
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Medical Necessity
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Summary Reviewer
A 22-year-old male enrollee has requested reimbursement for substance use outpatient services provided from 10/25/16 through 11/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is sufficient support in the medical literature for the services at issue in this clinical setting. Routine outpatient treatment is standard of care for patients with amphetamine use disorder. From 10/25/16 through 11/10/16, the patient was treated using EMDR therapy. EMDR is evidenced based practice in treating past psychological trauma which is a common comorbid condition for those with substance use disorders. Treatment with EMDR therapy in an outpatient setting is one of the least restrictive methods of delivering psychiatric care. This patient required treatment for his amphetamine disorder. As such, the documentation provided as well as the medical literature, support the services at issue. Therefore, in this patients case, substance use outpatient services provided from 10/25/16 through 11/10/16 were medically necessary for the treatment of this patient. Based on the reasons stated above, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned
| 1 |
A 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 8/20/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.
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Overturned
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Experimental
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Summary Reviewer 1
A 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 8/20/15. 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 due to the advantages tomosynthesis brings to radiologists in the interpretation of digital mammography, the American College of Radiology (ACR) statement on breast tomosynthesis has urged the technique be removed from the investigational category. The advantages relate to the separation of dense glandular tissue from underlying architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional (2D) mammographic views was likely of more benefit to the patient than had the study been done with 2D 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.
| 1 |
A 51-year-old male enrollee has requested reimbursement for a coronary computed tomography (CT) calcium scan provided on 3/15/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees hyperlipidemia.
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Upheld
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Medical Necessity
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Summary Reviewer
A 51-year-old male enrollee has requested reimbursement for a coronary computed tomography (CT) calcium scan provided on 3/15/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees hyperlipidemia. The physician reviewer found that use of the coronary CT calcium score has not been recommended as Class I indication by the American College of Cardiology (ACC). The ACC guidelines state that for asymptomatic patients, coronary calcium score is reasonable in the intermediate risk group but it has not achieved class I recommendation supporting routine use for all patients regardless of risk factors. Currently, the standard approach for risk stratification does not include coronary CT calcium scan in this clinical setting. Thus, the coronary CT calcium scan provided on 3/15/18 was not medically necessary for evaluation of this 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.
| 1 |
The patient is a 63-year-old female with a history of hypertrophic cardiomyopathy, non-sustained ventricular tachycardia. The patient has requested reimbursement for telemetry level of care provided from 3/13/20 through 3/16/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient.
had severe hypertrophic cardiomyopathy and known non-sustained ventricular tachycardia.
. Maintaining her in a cardiac telemetry monitored situation was medically necessary given the underlying arrhythmic substrate of her cardiomyopathy, coupled with the various surgical stresses. She had documented ventricular tachycardia postoperatively noted on the telemetry monitor and atrial fibrillation with rapid ventricular response, both of which
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Overturned
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Medical Necessity
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Summary Reviewer
The patient is a 63-year-old female with a history of hypertrophic cardiomyopathy, non-sustained ventricular tachycardia. The patient has requested reimbursement for telemetry level of care provided from 3/13/20 through 3/16/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that this patient had severe hypertrophic cardiomyopathy and known non-sustained ventricular tachycardia. At baseline, this patient is at a significantly higher risk for life threatening rhythm disturbances. Postoperatively, with the attendant injury and edema to the septal myocardium along with the marked electrolyte shifts of the postoperative period, she would be at even higher risk for life threatening rhythm disturbances. Maintaining her in a cardiac telemetry monitored situation was medically necessary given the underlying arrhythmic substrate of her cardiomyopathy, coupled with the various surgical stresses. She had documented ventricular tachycardia postoperatively noted on the telemetry monitor and atrial fibrillation with rapid ventricular response, both of which required immediate treatment in the perioperative period. Given her elevated risk of a life threatening arrhythmia, she was also not considered for discharge until an AICD had been implanted, making the necessity of postoperative cardiac monitoring all the more important. Therefore, telemetry level of care provided from 3/13/20 through 3/16/20 was medically necessary for the treatment of this patient.
| 1 |
A 20-year-old male enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation therapy from 6/30/16 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 behavioral health conditions.
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Upheld
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Medical Necessity
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Summary Reviewer
A 20-year-old male enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation therapy from 6/30/16 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 behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. Documents critical to the review, such as a psychiatric assessment, interpretative summary, serial progress notes, longitudinal history of the illness burden and outcomes of specific evidence-based psychotherapies and non-pharmacologic interventions, were not presented. The information provided, including the patients lengthy course of treatment with mood stabilizing and antipsychotic medications and poor tolerability of antidepressants, strongly suggests bipolar depression rather than a unilateral mood disorder and does not detail the influence of the patients psychiatric comorbid conditions. Considering transcranial magnetic stimulation is indicated for the acute phase treatment of major depressive disorder at this time, and the safety and effectiveness of transcranial magnetic stimulation therapy has not been established for other psychiatric disorders, the medical necessity of the services at issue cannot be established. All told, transcranial magnetic stimulation therapy from 6/30/16 forward was not and is 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.
| 0 |
A 58-year-old female enrollee has requested reimbursement for the anesthesia services provided on 11/1/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees gastritis.
the patient is an ASA status II, non-emergent patient who underwent evaluation with an upper endoscopy with MAC services. The records provided for review document the patients medical history includes low blood pressure. Sohn
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Upheld
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Medical Necessity
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Summary Reviewer
A 58-year-old female enrollee has requested reimbursement for the anesthesia services provided on 11/1/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees gastritis. The physician reviewer found that the patient is an ASA status II, non-emergent patient who underwent evaluation with an upper endoscopy with MAC services. The records provided for review document the patients medical history includes low blood pressure. Sohn and Ryu concluded that many procedures in and outside of the operating room, including eye surgery, otolaryngologic surgery, cardiovascular procedures, pain procedures, and endoscopy are performed with MAC to increase patient and operator satisfaction. However, a history of low blood pressure is not a medically indicated condition to warrant MAC for an upper endoscopy. All told, the anesthesia services provided on 11/1/16 were not medically necessary for evaluation of this patients gastritis. 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.
| 1 |
patient is a 63-year-old female who was diagnosed with metastatic colon cancer in December 2017. She was treated with surgery, but chemotherapy was delayed due to a patellar fracture, and she developed carcinomatosis.
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Upheld
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Medical Necessity
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Summary Reviewer
The patient is a 63-year-old female who was diagnosed with metastatic colon cancer in December 2017. She was treated with surgery, but chemotherapy was delayed due to a patellar fracture, and she developed carcinomatosis. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Kuter suggests that reduction in chemotherapy dose/frequency or alteration of regimen and platelet transfusions are the standard of care. Thrombopoietin receptor agonists such as eltrombopag are an alternate in patients who cannot be supported with transfusion and for whom reduction in dose/frequency would negatively impact survival. In this patients case, there is no indication that she could not be supported with either dose/regimen change or platelet transfusions.
Of note, the patients platelets are above the threshold for treatment with oxaliplatin, which is part of FOLFOX. Treatment with oxaliplatin only requires a platelet count of 75,000, which the patient has had. Therefore, Promacta 50 mg tablets are not medically necessary for the treatment of this patient.
| 1 |
A 52-year-old female enrollee has requested reimbursement for colorectal cancer screening; stool-based DNA and fecal occult hemoglobin performed on 9/16/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition.
p for a colonoscopy due to the triggering of migraines. The patient underwent stool-based DNA and fecal occult hemoglobin to screen for colon cancer.
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Overturned
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Experimental
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Summary Reviewer 1
A 52-year-old female enrollee has requested reimbursement for colorectal cancer screening; stool-based DNA and fecal occult hemoglobin performed on 9/16/15. 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 according to the documentation submitted for review, this patient is unable to tolerate prep for a colonoscopy due to the triggering of migraines. The patient underwent stool-based DNA and fecal occult hemoglobin to screen for colon cancer. These tests are considered an acceptable standard of care for colon cancer screening in average risk individuals. In addition, these tests will not trigger adverse symptoms and would detect a cancerous lesion and possibly avoid a colonoscopy. Given the above, the colorectal cancer screening; stool-based DNA and fecal occult hemoglobin performed on 9/16/15 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 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 58-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 12/28/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.
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Overturned
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Experimental
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Summary Reviewer 2
A 58-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 12/28/15. 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 services at issue were 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 medical literature cited above, 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 51-year-old male has requested reimbursement for gene expression profiling performed on 5/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma.
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Upheld
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Experimental
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Summary Reviewer 3
A 51-year-old male has requested reimbursement for gene expression profiling performed on 5/14/17. 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 (NCCN) guidelines states that 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 this testing was not likely to have altered treatment and surveillance recommendations. In sum, the superior effectiveness of gene expression profiling performed on 5/14/17 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.
| 1 |
A 50-year-old female enrollee has requested authorization and coverage for interstitial radiation
source application, complex, includes supervision, handling, loading of radiation source, when
performed. The Health Insurer has denied this request and reported that the requested service
is investigational for the treatment of the enrollees oligoprogressive hepatic disease.
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Upheld
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Experimental
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Summary Reviewer 1
A 50-year-old female enrollee has requested authorization and coverage for interstitial radiation
source application, complex, includes supervision, handling, loading of radiation source, when
performed. The Health Insurer has denied this request and reported that the requested service
is investigational for the treatment of the enrollees oligoprogressive hepatic disease. The
physician reviewer found that Y90 radioembolization has been shown to be an effective targeted
treatment for tumors of the liver. In this case, an applicator is used to directly infuse
microspheres of Y90 into the tumors. These microspheres are delivered through arteries that
feed directly into the tumor and emit a radionuclide which kills cancer cells. This allows for a very
targeted dose to be delivered. Liver tissue is highly radiosensitive so targeted therapies are
critical to ensure lower liver toxicity. At present, Y90 therapy has demonstrated a favorable
therapeutic ratio with improved overall survival outcomes and low toxicity rates. While there is
a lack of prospective, randomized trials directly comparing Y90 and other similar targeted liver
therapies, Y90 has continued to demonstrate a good safety profile. Tsang and colleagues report
that Y-90 was well-tolerated in patients with metastatic liver-dominant neuroendocrine tumors.
In phase 3 data combining Y90 therapy with systemic therapy in the setting liver metastases,
Chauhan and colleagues reported that the addition of the Y90 therapy showed significantly
longer progression-free survival and hepatic progression-free survival. Current medical literature
corroborates the low toxicity and improved overall survival data with Y90 therapy. Overall, Y90
has a track record of improving overall survival in the setting of liver metastases with a fairly low
toxicity profile. Given the disease burden seen within this patients liver, directed Y90
radioembolization with targeting of the liver metastases will likely be more beneficial than other
standard forms of treatment in this setting. Therefore, interstitial radiation source application,
complex, includes supervision, handling, loading of radiation source, when performed, is likely to
be more beneficial for treatment of the patients condition than any available standard therapy.
| 1 |
A 34-year-old female enrollee has requested reimbursement for homocysteine testing performed on 6/10/20 and 9/23/20. The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue.
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Upheld
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Experimental
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Summary Reviewer 2
A 34-year-old female enrollee has requested reimbursement for homocysteine testing performed on 6/10/20 and 9/23/20. The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. At issue is whether the services at issue were likely to have been more beneficial for evaluation of the enrollees condition than any available standard therapy. The physician reviewer found that the current medical evidence does not support the services at issue in this clinical setting. The records do not document a medical indication for the services at issue. It has no pertinent clinical usefulness, especially in a patient with normal thyroid function and normal hemoglobin levels. The records do not indicate that the patient was on immunosuppressive medications. The literature does not support the use of homocysteine level in this clinical scenario. Therefore, homocysteine testing performed on 6/10/20 and 9/23/20 was not likely to have been more beneficial than other methods of evaluating this patient.
| 0 |
A 60-year-old female enrollee has requested authorization and coverage for peroral endoscopic myotomy (POEM) and associated inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees esophageal achalasia.
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Overturned
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Experimental
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Summary Reviewer 3
A 60-year-old female enrollee has requested authorization and coverage for peroral endoscopic myotomy (POEM) and associated inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees esophageal achalasia. The physician reviewer found that the request for POEM and associated inpatient admission is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. POEM is a minimally invasive treatment for achalasia, and there is sufficient peer reviewed data to substantiate its safety and efficacy. Teitelbaum and colleagues studied patients who underwent POEM for treatment of esophageal motility orders. The authors reported that POEM resulted in successful palliation of symptoms in the majority of patients after five years. In this case, the patient is a good candidate for this minimally invasive therapy. POEM obviates the need for operative exploration and dealing with expected adhesive disease from her transplant. Therefore, the requested services are 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 |
patient is a 47-year-old female with a history of bed confinement with upper and lower extremity weakness and contractures with pain that prevents movement. On 11/30/16, the enrollee was transferred from Kindred Los Angeles Hospital to Cedars-Sinai Medical Center for follow-up appointment for cerebral arteriovenous shunt. The enrollee was monitored en route. The patient has requested reimbursement for the non-emergency ambulance service provided on 11/30/16. The Health Insurer has denied this request indicating that the service at issue was not medically necessary.
on 11/30/16. The patient is bedridden but does not require medical transportation.
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Upheld
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Medical Necessity
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Summary Reviewer
The patient is a 47-year-old female with a history of bed confinement with upper and lower extremity weakness and contractures with pain that prevents movement. On 11/30/16, the enrollee was transferred from Kindred Los Angeles Hospital to Cedars-Sinai Medical Center for follow-up appointment for cerebral arteriovenous shunt. The enrollee was monitored en route. The patient has requested reimbursement for the non-emergency ambulance service provided on 11/30/16. The Health Insurer has denied this request indicating that the service at issue was not medically necessary. This patients records do not include any clinical justification for the ambulance service provided on 11/30/16. The patient is bedridden but does not require medical transportation. The documentation suggests that the use of the ambulance was provided for patient convenience. Accordingly, the non-emergency ambulance service provided on 11/30/16 was not medically necessary for treatment of the patients medical condition. Based on the foregoing discussion, the service at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
The parent of an 11-year-old female enrollee has requested reimbursement for the FirstStep PLUS test provided on 11/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees severe attention deficit hyperactivity disorder (ADHD) and developmental delays.
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Overturned
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Experimental
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Summary Reviewer 3
The parent of an 11-year-old female enrollee has requested reimbursement for the FirstStep PLUS test provided on 11/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees severe attention deficit hyperactivity disorder (ADHD) and developmental delays. The physician reviewer found that CMA is recommended by the American College of Medical Genetics as a first-line test for patients with autism spectrum disorders. The yield of CMA in patients with autism spectrum disorders is estimated to be around 10%. While findings on CMA may not alter treatment of the features associated with autism spectrum disorders in all patients, CMA has become the standard of care in this clinical setting. Increasing numbers of patients with autism spectrum disorders have been found to have underlying copy number variations. As such, some copy number variations have also been associated with neuropsychological treatments or medications that have been shown to be more efficacious in this patient population. Additionally, copy number variations on CMA may inform about possible other complications and medical risks. All told, the FirstStep PLUS test provided on 11/23/16 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 34-year-old female enrollee has requested authorization and coverage for Xyrem 500 mg/ml oral solution. 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 was accurately diagnosed with narcolepsy without cataplexy. Her symptoms were not controlled with several stimulant medications. The patient has excessive daytime sleepiness, which responded to Xyrem.
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Overturned
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Medical Necessity
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Summary Reviewer
A 34-year-old female enrollee has requested authorization and coverage for Xyrem 500 mg/ml oral solution. 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 there is sufficient support for the requested services in this clinical setting. The patient was accurately diagnosed with narcolepsy without cataplexy. Her symptoms were not controlled with several stimulant medications. The patient has excessive daytime sleepiness, which responded to Xyrem. Xyrem has been approved by the U.S. Food and Drug Administration for the treatment of patients with narcolepsy type 2. Continuation of Xyrem treatment is critical to control this patients narcolepsy. Therefore, Xyrem 500 mg/mL oral solution is medically necessary for the treatment of this patient.
| 1 |
A 23-year-old transgender female enrollee has requested reimbursement for facial feminization surgery provided on 11/01/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria.
This patient has a documented history of gender dysphoria and has been on hormone therapy.
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Overturned
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Medical Necessity
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Summary Reviewer
A 23-year-old transgender female enrollee has requested reimbursement for facial feminization surgery provided on 11/01/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the current medical evidence supports the medical necessity of the services at issue. The services at issue were likely to have improved the patients psychological and social functioning. Per World Professional Association for Transgender Health (WPATH), medically necessary gender affirming/confirming surgical procedures include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, genital reconstruction, facial hair removal and certain facial plastic reconstruction. This patient has a documented history of gender dysphoria and has been on hormone therapy. Based on the documented history of gender dysphoria, facial feminization surgery was medically necessary for the treatment of this patient. Thus, facial feminization surgery provided on 11/01/18 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| 1 |
A 67-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy performed on 7/19/16. The Health Plan has denied this request indicating that the service at issue is considered investigational for treatment of the enrollee breast cancer.
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Upheld
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Experimental
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Summary Reviewer 1
A 67-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy performed on 7/19/16. The Health Plan has denied this request indicating that the service at issue is considered investigational for treatment of the enrollee breast cancer. The physician reviewer found that there is a lack of medical literature supporting the service at issue in this clinical setting. Silverstein and colleagues studied intraoperative radiotherapy for early-stage breast cancer. The study revealed that intraoperative radiotherapy was associated with a nine-fold increase in ipsilateral breast recurrence, although five-year overall survival was similar. In addition, the American Society for Radiation Oncology (ASTRO) consensus guidelines recommended intraoperative radiation therapy for those with suitable criteria with invasive cancer, and not for patients with DCIS. Moreover, treatment with intraoperative radiation therapy is not the standard therapy for breast cancer. Given the lack of support in the peer-reviewed literature, the intraoperative radiation therapy performed on 7/19/16 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 61-year-old male enrollee has requested authorization and coverage for intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures). The Health Insurer indicates that the requested services are investigational for the treatment of the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the requested services.
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Upheld
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Experimental
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Summary Reviewer 3
A 61-year-old male enrollee has requested authorization and coverage for intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures). The Health Insurer indicates that the requested services are investigational for the treatment of the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the requested services. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that the current medical evidence fails to demonstrate the superior efficacy of the requested services. There is a lack of support for intraoperative monitoring during a single-level lumbar fusion with pedicle screw placement. The cited articles discuss that the use of neural monitoring is associated with a higher cost without significant decrease in complication rate. Single-level lumbar fusion is below the spinal cord level, and neural monitoring is not recommended based on high-quality research. Therefore, intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures) is not likely to be more beneficial than any available standard therapy.
| 1 |
The patient is a 59-year-old male with a history of prior bilateral renal oncocytomas. The patient has requested reimbursement for cryoablation for kidney mass performed on 11/06/20. 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 patient had a renal tumor (oncocytomas) that was a stage T1 lesion. The patient declined active surveillance. The patient was not an
nephrectomy, given the history of recurrent oncocytomas. The tumor was not an angiomyolipoma.
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Overturned
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Medical Necessity
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Summary Reviewer
The patient is a 59-year-old male with a history of prior bilateral renal oncocytomas. The patient has requested reimbursement for cryoablation for kidney mass performed on 11/06/20. 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 that there is sufficient support for the services at issue in this clinical setting. The patient had a renal tumor (oncocytomas) that was a stage T1 lesion. The patient declined active surveillance. The patient was not an appropriate surgical candidate for nephrectomy or partial nephrectomy, given the history of recurrent oncocytomas. The tumor was not an angiomyolipoma. Radiofrequency cryoablation of the renal tumor is supported in this clinical scenario. The medical literature has demonstrated renal cryoablation to have similar or improved outcomes compared with nephrectomy. The studies consistently showed a lower decline in glomerular filtration rate with renal cryoablation. Therefore, cryoablation of the renal mass on 11/06/20 was medically necessary for the treatment of this patient.
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The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for inpatient rehabilitation treatment provided from 8/27/15 through 9/25/15. 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 severe scleroderma.
This patient presents with scleroderma leading to flexion contractures of his extremities, with resultant decrease in ability to perform activities of daily living and maintain normal function.
contractures is that he has significant skin fragility due to the scleroderma. He has progressed in inpatient therapy, but it is felt that he needs more time to reach his goals.
. He is getting assessments multiple times a day for skin breakdown, and coordinated care between therapists, nursing staff, and physicians to ensure that his skin is dry and intact. He is currently receiving constant adjustments in his splinting and casting to ensure
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Overturned
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Medical Necessity
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Summary Reviewer
The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for inpatient rehabilitation treatment provided from 8/27/15 through 9/25/15. 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 severe scleroderma. The physician reviewer found the submitted documentation establishes the medical necessity of the services at issue. This patient presents with scleroderma leading to flexion contractures of his extremities, with resultant decrease in ability to perform activities of daily living and maintain normal function. The difficult part of treating these contractures is that he has significant skin fragility due to the scleroderma. He has progressed in inpatient therapy, but it is felt that he needs more time to reach his goals. In this clinical setting, it is medically necessary for the patient to remain in inpatient rehabilitation due to the issue of the skin fragility. He is getting assessments multiple times a day for skin breakdown, and coordinated care between therapists, nursing staff, and physicians to ensure that his skin is dry and intact. He is currently receiving constant adjustments in his splinting and casting to ensure maximum benefit without breakdown of the skin. The risk of not treating this patient in an inpatient setting is worsening of hand function and skin breakdown leading to infection or chronic pain. As such, inpatient rehabilitation treatment provided from 8/27/15 through 9/25/15 was and is medically necessary for treatment of this patients medical condition. For the reasons provided, 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 57-year-old male enrollee has requested gene testing performed on 9/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.
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Overturned
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Experimental
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Summary Reviewer 1
A 57-year-old male enrollee has requested gene testing performed on 9/11/17. 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 that the testing performed in this case is a study of 15 to 31 genes in an individuals melanoma cells. It has been used to classify that melanoma as having either a high or low risk of metastasis. Per the medical evidence, this testing is particularly useful in the analysis and clinical follow-up of uveal melanoma. This has been validated in several studies and has become a standard test in this setting. Its clinical value lies in determining the need for intense surveillance and possibly to assist in the decision as to adjuvant therapy. Thus, gene testing performed on 9/11/17 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 58-year-old female enrollee has requested reimbursement for blepharoplasty of the upper eyelid performed on 12/07/18. 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.
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Upheld
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Medical Necessity
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Summary Reviewer
A 58-year-old female enrollee has requested reimbursement for blepharoplasty of the upper eyelid performed on 12/07/18. 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 there is a lack of support for the services at issue in this patients case. The blepharoplasty was not medically necessary based on the lack of appropriate visual field information. The visual fields provided were threshold tests in grayscale format. In order to determine superior eyelid scotoma, a suprathreshold static visual field is required. The provided fields did not demonstrate absolute superior scotomas, and printed results were in grayscale representation only, rather than the numerical visual field test results. This is not a reliable or appropriate visual field test to demonstrate superior visual field loss due to eyelid obstruction. Therefore, upper eyelid blepharoplasty performed on 12/07/18 was not medically necessary for the treatment of this patient.
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A 36-year-old male enrollee has requested reimbursement for monitored anesthesia provided during a colonoscopy on 4/30/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition.
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Upheld
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Medical Necessity
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Summary Reviewer
A 36-year-old male enrollee has requested reimbursement for monitored anesthesia provided during a colonoscopy on 4/30/15. 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 submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient did not present with a significant history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure. There is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. All told, monitored anesthesia was 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.
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A 32-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 4/12/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition.
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Overturned
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Experimental
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Summary Reviewer 3
A 32-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 4/12/21. 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 polymerase chain reaction testing has been compared to traditional testing for vaginitis. The literature supports the use of polymerase chain reaction testing because it results in significantly higher sensitivity and negative predictive value than clinical diagnosis or clinical testing. The test was also superior for detecting more than one cause for vaginitis. The medical evidence supports polymerase chain reaction testing as a means of accurate detection which allows for appropriate treatment. Therefore, polymerase chain reaction testing performed on 4/12/21 was likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.
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The parent of a 14-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 2/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition.
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Upheld
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Experimental
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Summary Reviewer 1
The parent of a 14-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 2/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Providers utilize the testing at issue as a standard therapy after starting infliximab to judge whether someone will benefit from the drug. It lets the provider know if the serum levels of drug are in the range to be beneficial and effective or if they have antibodies that could potentially lead to a reaction or failure to respond. This can help guide the provider in dosing or may lead to discontinue the drug if the patient is not likely to benefit from the medication. This can not only prevent the patient from having a flare, but save them from potential side effects of a drug they may not benefit from. The patient may be exposed to the drug unnecessarily without using this testing. Knowing this before a flare-up occurs can save the patient from a potential inpatient hospitalization as well. All told, 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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patient is a 44-year-old male with a history of hypothyroidism that is complicated by weight gain and hypercholesterolemia. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient.
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Upheld
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Medical Necessity
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Summary Reviewer
The patient is a 44-year-old male with a history of hypothyroidism that is complicated by weight gain and hypercholesterolemia. 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 is a common condition of thyroid hormone deficiency, which is readily diagnosed and managed but potentially fatal in severe cases if untreated. Synthetic thyroid hormone (levothyroxine) is the standard of care for patients with hyperthyroidism. Thyroid ultrasonography has established itself as a popular and useful tool in the evaluation and management of thyroid disorders. Indications for thyroid ultrasound include confirmation of the presence of a thyroid nodule, differentiation between benign and malignant masses, to assess for the presence of postoperative residual or tumor, to screen for patients at high risk for thyroid malignancy, and to provide information to help guide interventional procedures, such as a fine-needle aspiration biopsy. There is currently, however, no indication for routine thyroid ultrasound for patients with history of hypothyroidism alone. Therefore, 76536 (ultrasound, soft tissues of head and neck, real time image) performed on 1/27/21 was not medically necessary for the evaluation of this patient.
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A 31-year-old female enrollee has requested authorization and coverage for Uceris 2 mg rectal foam. 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.
This patient has left-sided ulcerative colitis based on colonoscopy and recent computed tomography scan. Budesonide foam primarily works in the rectum and left colon.
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Overturned
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Medical Necessity
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Summary Reviewer
A 31-year-old female enrollee has requested authorization and coverage for Uceris 2 mg rectal foam. 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 the submitted documentation supports the requested medication in this clinically setting. This patient has left-sided ulcerative colitis based on colonoscopy and recent computed tomography scan. Budesonide foam primarily works in the rectum and left colon. American College of Gastroenterology guidelines for the treatment of ulcerative colitis state that colonic delivery of budesonide offers more directed therapy and fewer systemic side effects than alternatives (given the high first-pass hepatic metabolism of budesonide), and that in patients with moderately active ulcerative colitis, non-systemic corticosteroids such as budesonide should be considered before the use of systemic therapy. The guidelines also recommend the use of topical rectal therapy before systemic therapy in distal colitis. Studies of budesonide foam have shown minimal systemic adverse effects, and that budesonide foam is well-tolerated and effective. A double-blind randomized trial by Naganuma and colleagues demonstrated effectiveness of budesonide foam in distal ulcerative colitis. Budesonide foam is supported as safe and effective for the treatment of distal colitis. Therefore, Uceris 2 mg rectal foam is medically necessary for the treatment of this patient.
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A 53-year-old female enrollee has requested authorization and coverage for a transcatheter aortic valve replacement (TAVR). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition.
the patient has severe aortic stenosis and requires valve replacement. She has a bicuspid valve, and given her age, she would likely need at least two chest surgeries owing to bioprosthetic valve degeneration over her lifetime.
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Upheld
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Experimental
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Summary Reviewer 2
A 53-year-old female enrollee has requested authorization and coverage for a transcatheter aortic valve replacement (TAVR). 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 the patient has severe aortic stenosis and requires valve replacement. She has a bicuspid valve, and given her age, she would likely need at least two chest surgeries owing to bioprosthetic valve degeneration over her lifetime. Her providers would like to initially attempt TAVR to obviate the need for surgical valve replacement at least until she reaches her 60s. TAVR has been studied and used successfully in low risk patients in a number of randomized published trials and carries an U.S. Food and Drug Administration (FDA) approval for this indication. The risk/benefit has been carefully weighed by the treating providers and the patient and an initial plan for non-surgical TAVR was made using the heart team and a shared decision making model based on AHA/ACC recommendations. There is support for the requested services in this clinical setting. Therefore, the requested TAVR is likely to be more beneficial than other available standard therapy.
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A 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 8/20/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.
In this case, the patient presented for a breast cancer screening with tomosynthesis.
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Overturned
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Experimental
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Summary Reviewer 2
A 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 8/20/15. 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 breast tomosynthesis performed on 8/20/15 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. In this case, the patient presented for a breast cancer screening with tomosynthesis. The study by Skaane and colleagues concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Based on the medical literature cited above, there is support for the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. 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 59-year-old male enrollee has requested reimbursement for substance abuse residential detoxification and rehabilitation services provided from 5/5/16 through 6/1/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse.
this patient was on a potentially life threatening detoxification from phenobarbital. Phenobarbital has a rather low LD50, and the patient demonstrated that he was unable to refrain from overuse of this and other substances, suggesting that he was
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Overturned
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Medical Necessity
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Summary Reviewer
A 59-year-old male enrollee has requested reimbursement for substance abuse residential detoxification and rehabilitation services provided from 5/5/16 through 6/1/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse. The physician reviewer found that this patient was on a potentially life threatening detoxification from phenobarbital. Phenobarbital has a rather low LD50, and the patient demonstrated that he was unable to refrain from overuse of this and other substances, suggesting that he was at high risk for overdose if detoxification was not conducted in a controlled environment. As such, medically conducted detoxification was appropriate until the doses of his phenobarbital were brought down to minimal levels. The records indicate the patients phenobarbital levels were safely at minimal levels by 5/11/16. Thus, by 5/12/16 he could have been stepped down to chemical dependency partial hospitalization program (CD-PHP) treatment. For these reasons, the substance abuse residential detoxification and rehabilitation services provided from 5/5/16 through 5/11/16 were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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.
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A patient is a 54-year-old male who was admitted to a residential treatment center (RTC) on
9/19/22 and presented for a psychological evaluation. The patient has requested reimbursement
for adult substance use disorder RTC from 9/26/22 through 10/17/22. The Health Insurer has
denied this request and reported that the services at issue were not medically necessary for the
treatment of this patient.
For dimension 1, the patient had a history of delirium
tremens, which has the potential to be fatal, and seizures when detoxifying from alcohol. The
records noted up to seven detoxification attempts within the past four years, without significant
sobriety. The patient was at high risk of death due to relapse and alcohol withdrawal. The patients
withdrawal symptoms were safely managed
. For
dimension 2, the patient reported medical symptoms including pain and swelling of his ankle and
calf cramps. The records noted that the patient had an infected finger and cellulitis in the bilateral
trunk.
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Overturned
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Medical Necessity
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Summary Reviewer
A patient is a 54-year-old male who was admitted to a residential treatment center (RTC) on
9/19/22 and presented for a psychological evaluation. The patient has requested reimbursement
for adult substance use disorder RTC from 9/26/22 through 10/17/22. 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 Society of Addiction Medicine (ASAM) criteria,
this patient met Level 3.5 criteria for RTC services from 9/26/22 through 10/17/22. ASAM criteria
focuses on six dimensions to determine the appropriate level of care, which includes: (1)
intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and
cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem
potential; and (6) recovery environment. For dimension 1, the patient had a history of delirium
tremens, which has the potential to be fatal, and seizures when detoxifying from alcohol. The
records noted up to seven detoxification attempts within the past four years, without significant
sobriety. The patient was at high risk of death due to relapse and alcohol withdrawal. The patients
withdrawal symptoms were safely managed in a level 3.5 setting. This criterion was met. For
dimension 2, the patient reported medical symptoms including pain and swelling of his ankle and
calf cramps. The records noted that the patient had an infected finger and cellulitis in the bilateral
trunk. This criterion was met. For dimension 3, the records noted both psychiatric and cognitive
difficulties throughout the patients stay, including impaired memory, circumspect answers,
pressured speech, and hyper-attentiveness to details. He required redirection, appeared confused,
and was described as anxious, with paranoia regarding hackers who were hijacking his life and
causing difficulties in his finding employment. The patient was on antipsychotic medication along
with gabapentin and hydroxyzine but remained anxious and exhibited classic symptoms for PTSD.
He was prescribed Prazosin but reported insomnia and nightmares. The patient reported a history
of anxiety and depression since age 12, when his brother committed suicide, citing this as a reason
for starting opioid use. The patient appeared to be at high suicide risk due to being unmarried and
unemployed, with alcohol and methamphetamine use disorders, a family history of suicide, and a
lack of contact with his son. This criterion was met. For dimension 4, the patient was in the
contemplative state of change. Although he had attended 12-step groups in the past, the patient
reported wanting an alternative. The patient endorsed moderate cravings. The patient did not
appear to be in the action stage of recovery/change. This criterion was met. For dimension 5, the
patient was at a high risk for relapse due to a long history of drug and alcohol use, little sobriety
time, lack of supports, and endorsement of cravings. The patient reported use of
methamphetamine, which could be causing his paranoid delusions and/or making them worse.
Continued use of methamphetamine would increase the patients paranoia and worsen his mental
health issues. This criterion was met. For dimension 6, the patient was unemployed due to his
mental health and substance abuse. He lived with his elderly father with whom he had a strained
relationship. The patient reported support from a girlfriend but had been separated from her since
2020. He lacked any support for his sobriety other than his current treatment team. This criterion
was met. Given these findings, the patient met the six ASAM criteria for RTC services provided
from 9/26/22 through 10/17/22. Accordingly, adult substance use disorder RTC from 9/26/22 through 10/17/22 was medically necessary for treatment of this patient.
| 1 |
The patient is a 60-year-old male who underwent a prostate biopsy in January 2019 and was diagnosed with prostate cancer. The patient has requested coverage for PET imaging CT attenuation skull base to mid-thigh. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient.
has a relatively low-grade prostatic malignancy, based on his Gleason
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Overturned
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Medical Necessity
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Summary Reviewer
The patient is a 60-year-old male who underwent a prostate biopsy in January 2019 and was diagnosed with prostate cancer. The patient has requested coverage for PET imaging CT attenuation skull base to mid-thigh. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. The physician reviewer found that a diagnosis of prostate cancer commonly presents patients with decisions that have no clear-cut answers. The patient is faced with a decision concerning the best therapeutic approach. Choices include: a radical prostatectomy, either with robotic assistance or via an open approach; external beam radiation; brachytherapy; and chemical or surgical castration. Some patients will even opt for no treatment. Further complicating the decision are the possible complications of therapy, including impotence, incontinence, infection, and bleeding. The prognosis also varies directly with Gleason scores. This particular patient has a relatively low-grade prostatic malignancy, based on his Gleason score. The next issue is how to monitor these patients. The National Comprehensive Cancer Network (NCCN) recommends following PSA levels, and when PSA levels increase on two successive assays, considering imaging such as chest x-rays, bone scans, CT, MRI, and PET scans. Prostate bed biopsy is also a consideration. It is expected that, following complete resection of the malignancy, the PSA will drop to 0. Progressive increases in PSA indicate that there is residual or recurrent tumor. One problem is the lack of accuracy of the various imaging modalities when the post-radical prostatectomy PSA levels are low, but rising. These patients generally will have a recurrence, but it will often be undetectable with conventional imaging modalities. Bone scans will be rarely positive in patients with PSA levels less than 10. Plain x-rays will generally not detect a lesion until 50% of the bone mineralization is lost or gained (sclerotic metastases). CT scans and MRI are dependent on the site scanned, and will only pick up gross anatomic distortions or disease. Microscopic or small lesions will be very difficult to detect. In order to effectively cover the areas detectable by PET scanning, one would have to perform CT or MRI scans of the head, neck, chest, abdomen, and pelvis. The value of PET scanning, especially when combined with CT scans is that they depend on metabolic changes to detect abnormalities. The U.S. Food and Drug Administration has approved a new radiopharmaceutical used for PET scanning of the prostate. This agent, fluciclovine (marketed as Axumin) offers two distinct advantages. Axumin can detect recurrent disease at PSA levels far less than can be detected by more conventional imaging techniques. Additionally, since Axumin accumulates in non-bony metastases as well as in bone, it offers the advantage of potentially localizing tumor in the prostate bed or in lymph nodes that might not be noted on cross-sectional studies. At this time, Axumin is only approved for cases that are post therapy, and is not approved as an initial screening or staging device. Once recurrence is identified and localized, targeted therapy such as radiation can be utilized. The use of Axumin PET/CT scan has also been supported by the National Comprehensive Cancer Network (NCCN) guidelines. The recommended Axumin PET/CT scan may assist in detecting metastases not appreciable by other modalities. Therefore, the requested PET imaging CT attenuation skull base to mid-thigh is medically necessary for the evaluation of this patient.
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A 58-year-old male enrollee has requested authorization and coverage for posterior cervical disc fusion C2-T2 and two bed days. 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.
well as myelopathy and a probable pseudarthrosis at C7-T1 and cervicothoracic kyphosis. There is a history of prior anterior and posterior cervical fusion. The provider is requesting revision surgery from C2 to T2 posteriorly. Loosening of the pedicle screws at C7 and intra-facet placement of the C3 screws are documented.
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Overturned
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Medical Necessity
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Summary Reviewer
A 58-year-old male enrollee has requested authorization and coverage for posterior cervical disc fusion C2-T2 and two bed days. 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 the records document a history of severe neck pain associated with radiculopathy as well as myelopathy and a probable pseudarthrosis at C7-T1 and cervicothoracic kyphosis. There is a history of prior anterior and posterior cervical fusion. The provider is requesting revision surgery from C2 to T2 posteriorly. Loosening of the pedicle screws at C7 and intra-facet placement of the C3 screws are documented. Per the literature, instability of the cervicothoracic junction is fairly common after a long cervical fusion. In the study by Truumees and colleagues, a total of 177 adult spine patients undergoing three or more levels of posterior cervical fusions for degenerative disease were included. According to this study, extension of the posterior cervical fusion into the thoracic spine leads to a lower pseudarthrosis rate. Furthermore, correction of the cervicothoracic kyphosis will also be necessary to relieve pain. Additionally, the proximal extension of the posterior construct to C2 is also necessary for stability in this long construct and for revision of the proximal intra-articular pedicle screws described by the provider. Therefore, posterior cervical disc fusion C2-T2 and two bed days are medically necessary for the treatment of this patient.
| 1 |
The parent of a 15-year-old female enrollee has requested reimbursement for psychiatric residential treatment center (RTC) services from 5/13/15 through 12/31/15. 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 patient was generally cooperative and participated in therapy. She was not aggressive, combative, or incoherent.
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Upheld
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Medical Necessity
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Summary Reviewer
The parent of a 15-year-old female enrollee has requested reimbursement for psychiatric residential treatment center (RTC) services from 5/13/15 through 12/31/15. 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 upon review of the documentation provided, records from 5/13/15 through 12/31/15 show no evidence that the patients behaviors were out of control, or that the patient was psychotic or a danger to herself or others. Moreover, the records do not indicate that the patient required any special medical or nursing treatment that could not have been provided in a setting other than 24-hour level of care. The notes indicate normal therapy sessions that could have taken place if the patient were an outpatient rather than in a residential setting. The patient was generally cooperative and participated in therapy. She was not aggressive, combative, or incoherent. There is no documentation of particular treatment techniques that would have required an inpatient treatment setting. The patients psychiatrists notes consistently show that the patient was making good progress and that both Seroquel and lithium were no longer needed and were discontinued. Based upon the information stated above, 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 17-year-old female enrollee has requested reimbursement for autonomic testing performed on 8/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees chronic fatigue and presumed postural orthostatic tachycardia syndrome (POTS).
of well-being. As part of the diagnostic work-up the patient received a comprehensive assessment of her autonomic nervous system with an evaluation that was positive for abnormal sudomotor function, borderline cardiovagal impairment and preserved cardiovascular adrenergic function.
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Overturned
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Experimental
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Summary Reviewer 2
The parent of a 17-year-old female enrollee has requested reimbursement for autonomic testing performed on 8/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees chronic fatigue and presumed postural orthostatic tachycardia syndrome (POTS). The physician reviewer found this patients provider was faced with a diagnostic conundrum of how much the patients chronic fatigue syndrome versus depression versus POTS were contributing to her overall loss of well-being. As part of the diagnostic work-up the patient received a comprehensive assessment of her autonomic nervous system with an evaluation that was positive for abnormal sudomotor function, borderline cardiovagal impairment and preserved cardiovascular adrenergic function. Given this patients presentation, evaluation with autonomic testing was appropriate because POTS may occur with co-morbidities including diabetes, chronic fatigue, sleep disturbances, dizziness, syncope, migraines, gastrointestinal disorders of a functional nature, fibromyalgia and joint hypermobility, but co-morbid conditions can occur with or without tilt-table-defined POTS. In addition, POTS subtypes can be defined by using small fiber and autonomic structural and functional criteria. Given the complexities in this patients case from a diagnostic perspective, the autonomic testing provided on 8/24/15 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.
| 1 |
The patient is a 65-year-old male with a medical history significant for episodes of diffuse paralysis during which he appears to be conscious and conversant but unable to move freely due to profound weakness. The patient has requested reimbursement for genetic testing performed on 3/25/20. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the evaluation of this patient.
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Overturned
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Medical Necessity
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Summary Reviewer
The patient is a 65-year-old male with a medical history significant for episodes of diffuse paralysis during which he appears to be conscious and conversant but unable to move freely due to profound weakness. The patient has requested reimbursement for genetic testing performed on 3/25/20. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that periodic paralysis is a group of inherited diseases that present as episodic muscle weakness and paralysis. Hyperkalemic Periodic Paralysis (HYPP, HyperKPP) is a rare condition that begins in childhood and can continue until middle adulthood or may even last into late adulthood. It presents as muscle weakness, ranging from mild weakness to paralysis. During these episodes, it is common to have higher than normal blood levels of potassium. The condition is caused by a mutation in the SCN4A gene that codes for voltage-gated sodium channel Na1.4. Several diagnostic modalities exist in assisting diagnosis, which includes genetic testing. Given the extreme phenotype of the patient in this case, coupled with the known molecular basis for periodic paralysis, genetic testing was medically necessary in order to provide adequate surveillance, enroll in studies and quantify recurrence risk. Therefore, genetic testing performed on 3/25/20 was medically necessary for the evaluation of this patient.
| 1 |
A 53-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition.
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Upheld
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Experimental
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Summary Reviewer 2
A 53-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index is believed to add a bit to these prognostics. DecisionDx-Melanoma gene expression testing is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the risk of recurrence at five years. Gerami and colleagues reported on 217 cases, with good correlation between DecisionDx-Melanoma classification and prognosis in patients undergoing sentinel node biopsy. At this time, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. It is also not clear if the DecisionDx-Melanoma assay can be used to make clinical decisions. All told, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than any available standard therapy.
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The parent of a five-year-old male enrollee has requested reimbursement for gene testing performed on 11/20/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees generalized epilepsy of unknown etiology.
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Overturned
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Experimental
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Summary Reviewer 3
The parent of a five-year-old male enrollee has requested reimbursement for gene testing performed on 11/20/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees generalized epilepsy of unknown etiology. The physician reviewer found that ezugha and colleagues studied 82 children with developmental delay or seizures. The study found abnormalities on CMA in 20 children (23.5%), but found the highest yield on CMA in those with four or more additional clinical variables, including seizures, hypotonia, learning delay, hypotonia, dysmorphic features, developmental delay, or autism. In children with three or fewer of these variables, like this patient who has no additional variables besides epilepsy, the yield of CMA was 8.7%. Given that this patient does not have heath concerns outside of seizures, the likelihood of abnormal finding on CMA is likely to be low. In addition, CMA is recommended as standard of care in children with intellectual or developmental disability or multiple congenital anomalies. This patient does not meet these criteria. As such, the gene testing performed on 11/20/15 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.
| 1 |
The patient is an eight-year-old male with a past psychiatric history of attention
deficit/hyperactivity disorder (ADHD), combined presentation, oppositional defiant disorder,
and rule out autism spectrum disorder. The patients parent has requested authorization and
coverage for dextroamphetamine-amphetamine ER 10 mg capsules SR 24H (#60 per 30 days).
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Overturned
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Medical Necessity
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Summary Reviewer
The patient is an eight-year-old male with a past psychiatric history of attention
deficit/hyperactivity disorder (ADHD), combined presentation, oppositional defiant disorder,
and rule out autism spectrum disorder. The patients parent has requested authorization and
coverage for dextroamphetamine-amphetamine ER 10 mg capsules SR 24H (#60 per 30 days).
The physician reviewer found it is a fairly common occurrence in clinical practice to prescribe a
long-acting stimulant (with a marketed duration of action of 12 hours) and have patients return
to the clinic saying that the medication only lasts for a much shorter period of time. Despite
the wide availability of long-acting stimulants which would eliminate the need for dosing
multiple times a day, many patients (or their parents) report relief of symptoms with taking
long-acting stimulant medications more than once per day or repeated use of short-acting
stimulants following a long-acting stimulant dose. According to the FDAs Medication Guide for
Adderall XR, On a mg/kg weight basis, children eliminated amphetamine faster than adults.
The elimination half-life (t1/2) is approximately 1 hour shorter for d-amphetamine and 2 hours
shorter for l-amphetamine in children than in adults. However, children had higher systemic
exposure to amphetamine (Cmax and AUC) than adults for a given dose of Adderall XR, which
was attributed to the higher dose administered to children on a mg/kg body weight basis
compared to adults. Upon dose normalization on a mg/kg basis, children showed 30% less
systemic exposure compared to adults. Individuals vary in the way they metabolize
medication, and this has led to the development of pharmacogenetic testing. Some individuals
may metabolize certain medications more rapidly than others and conversely there are others
who are considered slow metabolizers when compared to the majority of individuals who
metabolize medications at a typical rate. Those who metabolize medication more rapidly than
normal may require higher than usual medication doses or greater frequency of dosing as
seems to be the case with this patient. Given that the patient has had documented benefit from
twice daily dextroamphetamine-amphetamine ER (Adderall XR) dosing with no significant side
effects, dextroamphetamine-amphetamine ER 10 mg capsules SR 24H (#60 per 30 days) are
medically necessary for the treatment of this patient.
| 1 |
A 48-year-old female enrollee has requested reimbursement for genetic testing performed by Myriad Laboratories on 10/4/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for breast or ovarian cancer syndrome.
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Upheld
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Experimental
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Summary Reviewer 2
A 48-year-old female enrollee has requested reimbursement for genetic testing performed by Myriad Laboratories on 10/4/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for breast or ovarian cancer syndrome. The physician reviewer found that there is currently a lack of prospective randomized controlled studies showing improved outcomes with use of genetic testing in this setting. There is a paucity of data from clinical trials correlating the results obtained from similar tests with improved overall survival, progression free survival, or quality of life. Further, the National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncology (ASCO) guidelines encourage research to delineate the optimal use of panel-based testing, development of evidence-based practice guidelines as data emerges, and education of providers regarding challenges in the use of these tests (Daly, et al; Robson, et al). In the absence of data demonstrating improved health outcomes with use of these tests, the genetic testing performed by Myriad Laboratories performed on 10/4/17 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 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 58-year-old male enrollee has requested reimbursement for therapeutic phlebotomy from
1/6/21 through 1/26/21. The Health Insurer has denied this request and reported that the service
at issue was investigational for the treatment of the enrollees hereditary hemochromatosis.
, laboratory results dated 12/14/20 showed a ferritin of 369 ng/mL and an iron
saturation over 85%.
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Overturned
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Experimental
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Summary Reviewer 2
A 58-year-old male enrollee has requested reimbursement for therapeutic phlebotomy from
1/6/21 through 1/26/21. The Health Insurer has denied this request and reported that the service
at issue was investigational for the treatment of the enrollees hereditary hemochromatosis. The
physician reviewer found that therapeutic phlebotomy is the preferred approach to removing
iron in patients with hereditary hemochromatosis because it is highly effective and relatively
devoid of toxicities. In this case, phlebotomy was indicated as the records noted a biopsy proven
iron overload. While there is a range of ferritin and iron saturation goals, the recommended
ferritin goal is 30 to 150 ng/mL and the recommended iron saturation goal is greater than 20%.
In this case, laboratory results dated 12/14/20 showed a ferritin of 369 ng/mL and an iron
saturation over 85%. Therefore, therapeutic phlebotomy from 1/6/21 through 1/26/21 was likely
to have been more beneficial for treatment of the enrollee's condition than any available
standard therapy.
| 1 |
A 64-year-old male enrollee has requested authorization and coverage for cetuximab (Erbitux) to be given in conjunction with FOLFIRI. The Health Insurer has denied this request and reported that the requested medication regimen is investigational for the treatment of the enrollees medical condition.
This patient is receiving first-line therapy for metastatic disease given prior treatment in 2006.
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Overturned
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Experimental
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Summary Reviewer 3
A 64-year-old male enrollee has requested authorization and coverage for cetuximab (Erbitux) to be given in conjunction with FOLFIRI. The Health Insurer has denied this request and reported that the requested medication regimen is investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is no globally accepted first-line chemotherapy regimen for advanced, HER2-negative esophagogastric cancer, and practice is variable. Cetuximab in EGFR amplified tumors has been shown to be effective in patients with esophageal and gastric cancers and has been demonstrated to be well-tolerated in combination with fluorouracil based chemotherapy rather than other regimens. This patient is receiving first-line therapy for metastatic disease given prior treatment in 2006. There is sufficient support for the requested medication regimen in this setting. Thus, cetuximab (Erbitux) to be given in conjunction with FOLFIRI is likely to be more beneficial than any available standard therapy.
| 1 |
The patient is a 64-year-old male with a history of high-risk prostate cancer. The patient was
evaluated by a radiation oncologist who recommended a course of proton beam therapy. The
Health Insurer has denied the requested services as not medically necessary for treatment of the
patients medical condition.
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Upheld
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Medical Necessity
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Summary Reviewer
The patient is a 64-year-old male with a history of high-risk prostate cancer. The patient was
evaluated by a radiation oncologist who recommended a course of proton beam therapy. The
Health Insurer has denied the requested services as not medically necessary for treatment of the
patients medical condition. The physician reviewer found that overall, the utilization of proton
beam therapy is not recommended for routine use in the treatment of patients with prostate
cancer. Proton beam therapy has unique properties compared to standard photon beam therapy
in its ability to deposit radiation dose and can potentially result in fewer areas of low scattered
radiation dose. Proton beam therapy is currently utilized and most strongly indicated in settings
where severe toxicities would result if normal tissue constraints cannot be met by photon beam.
However, in the treatment of patients with prostate cancer, studies have failed to show that the
use of proton beam therapy results in a demonstrable, clinically significant difference in overall
survival, quality of life, or reduction of high-grade toxicities over photon beam therapy (Royce
and Efstathiou). Proton beam therapy may be efficacious in the treatment of patients with
prostate cancer in cases of unusual anatomy or in cases of re-irradiation of adjacent tissues.
Volumetric modulated arc therapy (VMAT) is a standard photon therapy radiation technique that
is frequently utilized to achieve clinically equivalent normal organ dose constraints as proton
beam therapy (Schroeck, et al.; Nogueira, et al.). Excellent dose toxicity outcomes have been
demonstrated for standard VMAT in locally advanced prostate cancer. In this case, the records
provided for review indicate that this patient has high-risk prostate cancer, but there is a lack of
documentation indicating that the patient had unusual anatomy or re-irradiation of adjacent
tissues. Therefore, the requested proton beam therapy is not medically necessary for treatment
of this patient.
| 1 |
A 58-year-old female enrollee has requested authorization and coverage for Ibrance 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees breast cancer.
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Overturned
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Experimental
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Summary Reviewer 2
A 58-year-old female enrollee has requested authorization and coverage for Ibrance 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees breast cancer. The physician reviewer found that Turner and colleagues reported that treatment with Ibrance and Faslodex is approved for ER positive metastatic disease. The authors reported that among patients with hormone receptor positive metastatic breast cancer who had progression of disease during prior endocrine therapy, Ibrance combined with Faslodex resulted in longer progression-free survival than Faslodex alone. Given this support, the requested Ibrance 100 mg is supported as 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 54-year-old male enrollee has requested authorization and coverage for anterior dual fusion. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.
The patient has well-documented multi-level cervical and lumbar degenerative disc disease. He has upper extremity neurological symptoms considered to reference cervical spine myelopathies.
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Upheld
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Medical Necessity
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Summary Reviewer
A 54-year-old male enrollee has requested authorization and coverage for anterior dual fusion. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support in the medical literature for spinal fusion for the management of chronic regional low back pain. A multicenter randomized study by Brox and colleagues compared the effectiveness of lumbar instrumented fusion with cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. The authors found there was no advantage over instrumentation and fusion versus the conservative treatment method. The patient has well-documented multi-level cervical and lumbar degenerative disc disease. He has upper extremity neurological symptoms considered to reference cervical spine myelopathies. However his studies do not demonstrate instability on flexion extension views. MRI revealed a stable grade 1 spondylolisthesis at L3-4. This would not be addressed with an L4-S1 fusion which would likely aggravate that condition by increasing stresses at that level after fusion. In addition, the diagnosis of neural foraminal stenosis at the lumbar spine is weakly supported with anatomical studies and even if present can be addressed with the posterior approach laminotomy foraminotomy without fusion. In addition, upper extremities symptoms suggest an undiagnosed neurological disorder as a comorbidity. Therefore, the anterior dual fusion is not medically necessary for treatment of the patients medical condition. For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
The patient is a 16-year-old male with short stature whose height ((shoe)?) measurement fell to less than the 3rd percentile at age 12 years. His weight tracked above the 5th percentile. He was evaluated in June 2015 and his peak growth hormone response to arginine and clonidine was 13 ng/mL. Insulin-like growth factor-1 (IGF-1) level was 232 ng/mL and insulin-like growth factor-binding protein 3 (IGFBP-3) was 2.6 mg/L. His thyroid function tests, serum chemistry panel, and hemoglobin were normal. His bone age in January 2016 was 13 year 6 months at 14 years 8 months. In June 2016, he stood at 151.4 cm (height standard deviation score of -2.3), and his growth velocity was 5.0 cm per year. He was started on Nutropin in October 2016 for treatment of idiopathic short stature. In January 2017, his height was 156.7 cm (height standard deviation score of -2.01) and his weight was 50.3 kg (weight standard deviation score of -1.06). His height velocity was 9.1 cm per year. Pubic hair was between Tanner stages 3 to 4, and testicular volume was 15 cc. The patients parent has requested authorization and coverage for Nutropin AQ NuSpin 20 mg/2 mL pen injector to optimize height potential for the patient. The Health Plan has denied this request and reported that the requested medication is not medically necessary for treatment of this patient.
The patient is being treated for idiopathic short stature, and as of January 2017 appear to be in the midst of his pube
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Overturned
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Medical Necessity
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Summary Reviewer
The patient is a 16-year-old male with short stature whose height ((shoe)?) measurement fell to less than the 3rd percentile at age 12 years. His weight tracked above the 5th percentile. He was evaluated in June 2015 and his peak growth hormone response to arginine and clonidine was 13 ng/mL. Insulin-like growth factor-1 (IGF-1) level was 232 ng/mL and insulin-like growth factor-binding protein 3 (IGFBP-3) was 2.6 mg/L. His thyroid function tests, serum chemistry panel, and hemoglobin were normal. His bone age in January 2016 was 13 year 6 months at 14 years 8 months. In June 2016, he stood at 151.4 cm (height standard deviation score of -2.3), and his growth velocity was 5.0 cm per year. He was started on Nutropin in October 2016 for treatment of idiopathic short stature. In January 2017, his height was 156.7 cm (height standard deviation score of -2.01) and his weight was 50.3 kg (weight standard deviation score of -1.06). His height velocity was 9.1 cm per year. Pubic hair was between Tanner stages 3 to 4, and testicular volume was 15 cc. The patients parent has requested authorization and coverage for Nutropin AQ NuSpin 20 mg/2 mL pen injector to optimize height potential for the patient. The Health Plan has denied this request and reported that the requested medication is not medically necessary for treatment of this patient. This denial is the subject of this appeal and determination. The patient is being treated for idiopathic short stature, and as of January 2017 appear to be in the midst of his pubertal growth spurt. Prior to initiation of growth hormone (GH), the patients height was 2.3 standard deviation score below the mean for his age and gender. His growth velocity was slow for age, and his bone age was mildly delayed. According to the Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SD) below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity less than the 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets the above criteria. Accordingly, Nutropin AQ NuSpin 20 mg/2 mL pen injector is medically necessary for treatment of this patient. Therefore, for the reasons state above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
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A 25-year-old female enrollee has requested reimbursement for calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20. The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue.
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Overturned
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Experimental
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Summary Reviewer 2
A 25-year-old female enrollee has requested reimbursement for calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20. The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that the fecal calprotectin is useful to assess disease activity in Crohns disease. Kawashima and colleagues conducted a study to clarify the predictability of fecal calprotectin level for predicting endoscopic remission. The authors noted that fecal calprotectin was more accurate for predicting endoscopic remission in Crohns disease than C-reactive protein, albumin, white blood cell count, and platelet count. DHaens and colleagues noted that fecal calprotectin levels correlate significantly with endoscopic disease activity in inflammatory bowel disease. There is sufficient support for the services at issue in this clinical setting. Therefore, calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20 was likely to have been more beneficial than other available standard therapy.
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A 60-year-old male enrollee has requested reimbursement for the subtalar arthrodesis provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees hallux valgus.
that this patient presents with an adult onset painful flatfoot and hallux valgus. The treatment under review had been successfully used on the other foot, which consisted of a calcaneal osteotomy, subtalar arthroereisis and tight wire management of hallux valgus.
. This patients care included a soft tissue hallux valgus tethering with rear foot re-orienting.
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Upheld
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Experimental
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Summary Reviewer 1
A 60-year-old male enrollee has requested reimbursement for the subtalar arthrodesis provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees hallux valgus. The physician reviewer found that this patient presents with an adult onset painful flatfoot and hallux valgus. The treatment under review had been successfully used on the other foot, which consisted of a calcaneal osteotomy, subtalar arthroereisis and tight wire management of hallux valgus. As isolated arthroereisis has limited benefit, when accompanied by other flatfoot correcting procedures, it has the ability to provide better results than attempting the subtalar blocking procedure alone. This patients care included a soft tissue hallux valgus tethering with rear foot re-orienting. In concert with the calcaneal osteotomy, a second procedure increases the potential for an improved result. The subtalar implant is not a procedure that should be performed alone and it does have complications but it appears to have the potential to provide a better outcome. Thus, the subtalar arthrodesis provided on 11/23/15 was 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 59-year-old male enrollee has requested reimbursement for gene testing performed on 9/13/16. The Health Insurer has denied this request indicating that the requested services were not medically necessary for evaluation of the enrollees cutaneous melanoma.
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Upheld
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Medical Necessity
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Summary Reviewer
A 59-year-old male enrollee has requested reimbursement for gene testing performed on 9/13/16. The Health Insurer has denied this request indicating that the requested services were not medically necessary for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of clinical trials. There is lack of evidence as to its efficacy and how the results would change treatment recommendations, such as in this case. Accordingly, the services at issue are not considered to be standard of care in this clinical setting. Therefore, gene testing performed on 9/13/16 was not medically necessary for the evaluation of this patients medical condition. Based on the information above, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
A 63-year-old female enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) performed on 3/14/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.T
In her case, her daughter developed relatively severe breast cancer at age 42. For this patient, MRI was warrante
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Overturned
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Experimental
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Summary Reviewer 2
A 63-year-old female enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) performed on 3/14/16. 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 MRI has an important role in both screening and diagnostic settings. In the last several years, several organizations, including the American Cancer Society and the American College of Radiology, have attempted to establish guidelines for the appropriate use of breast MRI. The medical literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. In this patients case, the records document a calculated lifetime risk for developing breast cancer of 26.4%. The National Comprehensive Cancer Network recommends that annual breast MRI be considered and begun 10 years prior to the age at which the youngest relative developed breast cancer. In her case, her daughter developed relatively severe breast cancer at age 42. For this patient, MRI was warranted. Therefore, MRI of the breasts performed on 3/14/16 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.
| 1 |
A 59-year-old male enrollee has requested authorization and coverage for spinal cord stimulator. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrollees medical condition.
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Overturned
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Medical Necessity
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Summary Reviewer
A 59-year-old male enrollee has requested authorization and coverage for spinal cord stimulator. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the requested device in this clinical setting. Wong and colleagues concluded that the option of spinal cord stimulation should be considered after conservative therapy has failed. They pointed to large randomized control studies which showed that high frequency forms of stimulation was effective for chronic low back pain. A systematic review and meta-analysis by Taylor and colleagues concluded that spinal cord stimulation is an effective pain relieving treatment for chronic low back and leg pain with or without a prior history of back surgery. The mean level of pain relief across 74 studies was found to be 58% at an average follow-up of 24 months. All told, the requested spinal cord stimulator is medically necessary for the treatment of this patient.
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A 22-year-old female enrollee has requested authorization and coverage for Orencia. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees rheumatoid arthritis.
with presumed active seronegative rheumatoid arthritis who is intolerant to methotrexate.
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Upheld
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Medical Necessity
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Summary Reviewer
A 22-year-old female enrollee has requested authorization and coverage for Orencia. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees rheumatoid arthritis. The physician reviewer found that the current guidelines recommend tumor necrosis factor (TNF) inhibitors as first-line therapy for patients with active rheumatoid arthritis. The U.S. Food and Drug Administration (FDA) has approved Orencia for the treatment of patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more disease modifying anti-rheumatic drugs (DMARDs) or TNF inhibitors (Maxwell and Singh). Orencia appears to be most effective in patients with active rheumatoid arthritis resistant to either methotrexate or the combination of methotrexate and anti-TNF agents and methotrexate naive patients with early rheumatoid arthritis and poor prognostic indicators (Kremer, et al). These indicators include patients who are methotrexate naive and seropositive for rheumatoid factor (RF), anti-cyclic citrullinated protein (CCP) type 2 or both and had radiographic evidence of joint erosions (Westhovens, et al). This is a case of a patient with presumed active seronegative rheumatoid arthritis who is intolerant to methotrexate. However, the medical records fail to demonstrate what dose and what reaction she had to the methotrexate. Moreover, the documentation does not include evidence of failure or intolerance or contraindications to TNF inhibitors. All told, Orencia is not supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma test performed on 10/19/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition.
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Upheld
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Medical Necessity
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Summary Reviewer
A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma test performed on 10/19/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that 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. 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. Therefore, DecisionDx-Melanoma testing provided 10/19/18 was not medically necessary for the evaluation of this patient.
| 0 |
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.
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Overturned
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Experimental
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Summary Reviewer 3
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 Autism spectrum disorder is a biologically based neurodevelopmental disorder. Identification of a genetic diagnosis may provide additional information about prognosis, expected outcome, and recurrence risk. However, few studies have evaluated the effect of genetic testing on such outcomes, and it is unclear whether or not genetic testing affects health outcomes. In this case, the documentation does not show how using genetic testing to diagnose autism spectrum disorder will directly impact treatment options. In sum, the superior efficacy of FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis has not been established. Based upon the information set forth above, the requested services are 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 |
The parent of a 17-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment provided from 6/28/19 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.
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Overturned
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Medical Necessity
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Summary Reviewer
The parent of a 17-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment provided from 6/28/19 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 the American Psychiatric Association treatment guidelines for eating disorders recommend either an inpatient unit or residential treatment facility when lower levels of care have been tried and failed. Additionally, the presence of comorbid conditions is an important factor to consider when deciding on the appropriate level of care. This patients comorbidities include major depressive disorder with suicidal ideation. Brewerton and Costin noted that for patients with anorexia nervosa there were statistically significant improvements in mean body mass indexThe great majority of patients completing treatment showed significant improvement at discharge from intensive residential treatment. This patient is experiencing a disturbance in mood, affect or cognition resulting in disordered eating behavior that could not be safely managed in a less restrictive setting. Therefore, residential treatment is in accordance with generally accepted standards of medical practice. Thus, mental health residential treatment from 6/28/19 forward was and is medically necessary for the treatment of this patient.
| 0 |
A 40-year-old male enrollee has requested reimbursement for acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees abdominal pain.
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Upheld
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Experimental
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Summary Reviewer 3
A 40-year-old male enrollee has requested reimbursement for acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees abdominal pain. The physician reviewer found the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Most studies regarding acupuncture for the treatment of abdominal pain are inconclusive. Lan and colleagues stated that It remains unknown whether manual acupuncture or electroacupuncture is more effective or safer than other treatments for patients with [functional dyspepsia] FD. Given the lack of support in the peer-reviewed literature, acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15 were 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 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 |
A 24-year-old male enrollee has requested reimbursement for mental health inpatient treatment from 8/03/16 through 8/04/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.
. This patient had an underlying formal thought disorder with violent outbursts at home and recent aggression with homicidal ideation. On 8/03/16, the patient remained psychotic, anxious and guarded. He was assessed to have poor insight, judgment and impulse control. The provider further determined that the patient remained a potential threat to self and others due to his psychotic burden. After liaising with family and the outpatient psychiatrist, a medication change was made on 8/03/16, and a rather recently released antipsychotic medication, cariprazine, replaced one of the other antipsychotic agents. In sum, on 8/03/16, the patient was still suffering from the illness burden that prompted the admission. He was engaged in active treatment during the entire hospital stay, which included evidence-based psychiatric care and
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Overturned
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Medical Necessity
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Summary Reviewer
A 24-year-old male enrollee has requested reimbursement for mental health inpatient treatment from 8/03/16 through 8/04/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue. Premature discharge of patients with severe mental illness and prominent psychosis not only increases patient morbidity and the chances of prompt re-admission, but also exposes the general population to preventable risk of harm. This patient had an underlying formal thought disorder with violent outbursts at home and recent aggression with homicidal ideation. On 8/03/16, the patient remained psychotic, anxious and guarded. He was assessed to have poor insight, judgment and impulse control. The provider further determined that the patient remained a potential threat to self and others due to his psychotic burden. After liaising with family and the outpatient psychiatrist, a medication change was made on 8/03/16, and a rather recently released antipsychotic medication, cariprazine, replaced one of the other antipsychotic agents. In sum, on 8/03/16, the patient was still suffering from the illness burden that prompted the admission. He was engaged in active treatment during the entire hospital stay, which included evidence-based psychiatric care and communication with family and outpatient providers to promote a seamless transition back to the community. During the disputed timeframe, the acute inpatient setting was reasonably expected to both improve the patients condition and prevent a more serious episode of illness. Thus, mental health inpatient treatment from 8/03/16 through 8/04/16 were medically indicated for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| 1 |
A 50-year-old male enrollee has requested reimbursement for mandibular advancement device (E0486) provided on 12/14/18. The Health Insurer has denied this request and reported that the device at issue was not medically necessary for the treatment of the enrollees medical condition.
the Health Insurer denied reimbursement for the device at issue claiming that the patient did not fail continuous positive airway pressure (CPAP) treatment as a first-line of treatment prior to use of the mandibular advancement device. The Health Insurer also noted that the patient did not qualify to be diagnosed with obstructive sleep apnea as his apnea-hypopnea index was 4 per hour, and his RDI was 12 per hour.
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Overturned
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Medical Necessity
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Summary Reviewer
A 50-year-old male enrollee has requested reimbursement for mandibular advancement device (E0486) provided on 12/14/18. The Health Insurer has denied this request and reported that the device at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the Health Insurer denied reimbursement for the device at issue claiming that the patient did not fail continuous positive airway pressure (CPAP) treatment as a first-line of treatment prior to use of the mandibular advancement device. The Health Insurer also noted that the patient did not qualify to be diagnosed with obstructive sleep apnea as his apnea-hypopnea index was 4 per hour, and his RDI was 12 per hour. The term RDI has been defined differently when used with portable monitors (home sleep study). Portable monitors are likely to underestimate the severity of events compared to the apnea-hypopnea index by polysomnography. The American Academy of Sleep Medicine recommends that providers consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. This recommendation supports the use of mandibular advancement device if the patient prefers it as a first-line of treatment even without showing intolerance to CPAP. Therefore, the mandibular advancement device provided on 12/14/18 was medically necessary for the treatment of this patient.
| 1 |
A 45-year-old female enrollee has requested reimbursement for FoundationOne gene testing performed on 3/26/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees adenosarcoma of the cervix.
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Overturned
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Experimental
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Summary Reviewer 1
A 45-year-old female enrollee has requested reimbursement for FoundationOne gene testing performed on 3/26/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees adenosarcoma of the cervix. The physician reviewer found the molecular profiling of an individuals cancer cells is an assay of genomic of molecular abnormalities. The goal would be to identify a target at which a specific treatment could then be offered. Though of real scientific interest, as yet there is a lack of convincing evidence that the assay adds to the decision making ability to improve patient outcomes. Von Hoff and colleagues, in a pilot study, explored the value of molecular profiling but the results are not convincing. The seriousness of utilizing molecular profiling is expressed in various medical literature but ongoing research must still be explored. In an editorial, Doroshow noted the serious limitations of various non-randomized studies exploring the value of molecular profiling. This viewpoint was also expressed in an editorial by West in 2016. Moreover, a recent randomized trial did not demonstrate significant clinical benefit from choosing therapy based on molecular targets (LeTourneau, et al). Therefore, the services at issue were not likely to be superior to any available standard therapy for treatment of this patients cancer. 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.
| 1 |
A 37-year-old male enrollee has requested authorization and coverage for placing devices in neck (insertion of more than one artificial intervertebral disc). The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition.
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Upheld
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Experimental
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Summary Reviewer 2
A 37-year-old male enrollee has requested authorization and coverage for placing devices in neck (insertion of more than one artificial intervertebral disc). The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition. The physician reviewer found that the requested neck surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Two level total disc arthroplasty has become accepted by the community of spinal surgeons, both neurosurgeons, and orthopedists, to be superior in most instances, to a two level fusion. There is a growing body of evidence in the peer-reviewed literature that demonstrates two level total disc replacement is associated with a lesser incidence of adjacent level disease than a two level anterior cervical fusion. 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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A 64-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer.
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Upheld
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Experimental
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Summary Reviewer 1
A 64-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that upon review of available data, proton therapy may be equivalent to, but not more beneficial than standard available therapy with photon based intensity modulated radiation therapy (IMRT) for prostate cancer. Proton therapy provides a Bragg peak, resulting in decreased dose before and after the peak, which translates into a decrease in exposure of normal tissue in the low- to intermediate-dose range, but not in the high-dose range (Trofimov, et al). Dosimetric studies have shown a benefit in bladder and rectal exposure with this regard. However, these findings do not appear to result in decreased clinical side effect (Sheets, et al; Coen, et al; Yu, et al; Hoppe, et al). Cancer control rates are also reportedly similar between photons and protons (Coen, et al). Accordingly, the requested proton beam radiation therapy 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 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.
| 1 |
patient is a 20-year-old female who has a history of alopecia totalis. The patient has requested authorization and coverage for Xeljanz (tofacitinib citrate tablet 5 mg). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient.
This patient has already had a trial of Xeljanz, is tolerating it well, and is achieving a reduction in her SALT score.
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Overturned
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Medical Necessity
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Summary Reviewer
The patient is a 20-year-old female who has a history of alopecia totalis. The patient has requested authorization and coverage for Xeljanz (tofacitinib citrate tablet 5 mg). 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 there is sufficient support for the requested medication in this clinical setting. Standard of care for the treatment of alopecia totalis/universalis includes systemic steroids, methotrexate, cyclosporine, Janus kinase inhibition, and contact sensitization with diphenylcylopropenone or squaric acid. Few treatment methods have been evaluated by randomized controlled trials to determine the most efficacious modalities to treat alopecia areata. Therefore, it is challenging for clinicians to guide patients regarding the best therapeutic options. Janus kinase inhibitors, like Xeljanz, do show excellent promise and some great results in treating extensive alopecia. This patient has already had a trial of Xeljanz, is tolerating it well, and is achieving a reduction in her SALT score. Janus kinase inhibition has been found to be well tolerated and effective in the treatment of alopecia. Therefore, Xeljanz (tofacitinib citrate tablet 5 mg) is medically necessary for the treatment of this patient.
| 1 |
A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 6/01/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.
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Overturned
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Experimental
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Summary Reviewer 1
A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 6/01/15. 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 there is sufficient support for the services at issue in this clinical setting. As noted by Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Per Ciatto and colleagues, integrated two-dimensional and three-dimensional mammography improves breast-cancer detection and has the potential to reduce false positive recalls. All told, digital breast tomosynthesis performed on 6/01/15 was likely to have been superior over other methods of evaluation. 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 60-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer.
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Upheld
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Experimental
|
Summary Reviewer 1
A 60-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that the most recent National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer summarize the published literature and discuss that dosimetric comparisons studies between proton therapy and intensity modulation radiation therapy (IMRT) do not predict accurately clinically meaningful endpoints. The NCCN guidelines acknowledge ongoing clinical studies and state that there is a lack of evidence supporting a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. All told, the peer-reviewed medical literature does not indicate the requested proton beam radiation therapy is likely to be more beneficial for treatment of this patients prostate cancer than
conventional alternatives. Based upon the information set forth above, I have determined 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.
| 1 |
A 45-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain.
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Overturned
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Experimental
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Summary Reviewer 3
A 45-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain. The physician reviewer found that surgical implantation of healthy cartilage cells (autologous chondrocyte implantation) is an alternative option for the treatment of large articular cartilage defects. Autologous chondrocyte implantation is primarily used to treat full-thickness cartilaginous defects of the distal femur by arthroscopically extracting healthy chondrocyte cells from the patients knee, culturing the cells, and implanting them back into an articular defect via an open surgical procedure. In general, autologous chondrocyte implantation is recommended as a second-line surgical option either after failure of initial arthroscopic repair or when a full-thickness articular cartilage defect is very large (2.5 cm2 or greater). Autologous chondrocyte implantation should also be avoided in obese patients who have been shown to have no sustained improvement at two years. Worse outcomes have been reported in females with autologous chondrocyte implantation, especially in patients with patellar defects. Weak evidence has suggested some success with patellar autologous chondrocyte implantation, which remains off-label, but quality randomized controlled trials are lacking. In this patients case, the records noted a bipolar chondral lesion of the patellofemoral joint, which is a contraindication for autologous chondrocyte implantation. The failure rate of this procedure is high in this location. Thus, autologous chondrocyte implantation of the knee is not likely to be more efficacious than other treatment options. 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.
| 1 |
A 62-year-old male has requested authorization and coverage for cervical total disc arthroplasty. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees neck pain and radiculopathy of arm.
this patient has a history of anterior cervical discectomy and fusion at C5-C6 and adjacent segment disease at C4-C5 with a large herniation. There is evidence of a right C5 radiculopathy.
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Upheld
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Experimental
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Summary Reviewer 3
A 62-year-old male has requested authorization and coverage for cervical total disc arthroplasty. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees neck pain and radiculopathy of arm. The physician reviewer found this patient has a history of anterior cervical discectomy and fusion at C5-C6 and adjacent segment disease at C4-C5 with a large herniation. There is evidence of a right C5 radiculopathy. Conservative treatment has been tried and failed. A review of the recent literature reveals that artificial disc replacement is superior to anterior cervical discectomy and fusion in that it will allow motion. The requested procedure can maintain the range of motion of the replaced segment as well as the adjacent unfused segment. Based on this analysis, fusion plus disc replacement procedure has less severe biomechanical effects on adjacent levels when compared to bi-level fusion procedure. Thus, the cervical total disc arthroplasty is likely to be of greater benefit than other 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.
| 1 |
A 33-year-old male enrollee has requested reimbursement for Prometheus Anser ADA diagnostic testing performed on 5/19/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease.
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Upheld
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Experimental
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Summary Reviewer 2
A 33-year-old male enrollee has requested reimbursement for Prometheus Anser ADA diagnostic testing performed on 5/19/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the Prometheus Anser ADA test is a quantitative measurement of serum adalimumab and anti-ADA antibodies. Some evidence exists that low serum levels of ADA or the presence of ADA antibodies have an adverse effect on the clinical outcome of a patients response to treatment. There are few well controlled clinical trials to confirm that use of the Anser ADA test leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). Moreover, in patients with IBD who lose response to ADA, clinical improvement may occur upon intensification of ADA therapy, irrespective of ADA serum concentration or presence of anti-ADA antibodies (Steenholdt, et al). As such, the clinical utility of measuring drug antibody concentrations is on a case-by-case basis. Based on the clinical documentation submitted for review, it has not been established how this patients specific management would change based on test results. In addition, there are technical factors relating to the use of different assay methods across studies. It has not yet been established whether the use of threshold levels aids in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established, such as in this case. For the reasons provided, the Prometheus Anser ADA diagnostic testing performed on 5/19/14 was not more beneficial for treatment of the patients medical condition than conventional treatment strategies. 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.
| 1 |
The parent of a 14-year-old male enrollee has requested reimbursement for wilderness treatment therapy provided from 7/16/18 through 8/30/18. 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 records noted moderate functional impairment, due to conflict with family members and problematic interactions with peers.
deterioration in functioning after transitioning to middle school,
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Upheld
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Experimental
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Summary Reviewer 1
The parent of a 14-year-old male enrollee has requested reimbursement for wilderness treatment therapy provided from 7/16/18 through 8/30/18. 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 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 this case, the appropriate level of care must be determined before the suitability of wilderness treatment can be assessed. With regard to risk of harm, the records support a score of 3. The documentation noted impulsive behaviors and outbursts, as well as the risk of victimization by peers. No episodes of physical aggression are reported in the six months prior to enrollment in the wilderness program. In terms of functional status, the records support a score of 3. The records noted moderate functional impairment, due to conflict with family members and problematic interactions with peers. With regard to comorbidity, the records support a score of 2, due to the combination of mental illness and possible mild neurodevelopmental disorder. In terms of level of stress of the recovery environment, the records support a score of 2. The environment was mildly stressful, due to recent change in school. With regard to environmental support, the records support a score of 1. The environment was highly supportive due to his parents involvement in treatment, ability to provide resources, and efforts to provide support for patient. In terms of resiliency and treatment history, the records support a score of 3. The records document deterioration in functioning after transitioning to middle school, and lack of remorse for his actions. With regard to acceptance and engagement, the records support a score of 3. The patient was incompletely engaged, due to his failure to accept responsibility for his actions. Thus, the patient has a total score of 17. Therefore, the appropriate level of care was high-intensity community-based services. In sum, wilderness treatment therapy provided from 7/16/18 through 8/30/18 was not likely to have been more beneficial than other treatment options.
| 1 |
The parent of a 17-year-old male enrollee has requested reimbursement for the mental health inpatient services provided from 5/31/18 through 6/6/18. 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.
. Per the documentation dated 5/31/18, the patient remained symptomatic. He was noted to be isolative and functioning below the level of his peers. He continued to endorse grandiose delusions, had disorganized thought process, as well as poor insight and judgment.
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Overturned
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Medical Necessity
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Summary Reviewer
The parent of a 17-year-old male enrollee has requested reimbursement for the mental health inpatient services provided from 5/31/18 through 6/6/18. 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 that according to the American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII), the mental health inpatient services provided from 5/31/18 through 6/6/18 were medically necessary. Per the documentation dated 5/31/18, the patient remained symptomatic. He was noted to be isolative and functioning below the level of his peers. He continued to endorse grandiose delusions, had disorganized thought process, as well as poor insight and judgment. Based on the documented history and clinical status, the patient met CASII service intensity criteria for secure 24-hour service with psychiatric management for the dates of service at issue. Moreover, the current medical literature supports that the continued services were medically necessary (Gray and Squeglia; Starzer, et al). Therefore, the mental health inpatient services provided from 5/31/18 through 6/6/18 were medically necessary for treatment of this patients behavioral health issues. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| 1 |
A 19-year-old female enrollee has requested authorization and coverage for liposuction, CPT code 15879 (suction assisted lipectomy of the lower extremity) and 38999 (unlisted procedure hemic or lymphatic system). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees lipedema. The physician reviewer found that the patient has well documented evidence of chronic, painful lipedema of the lower extremities that is affecting her ability to ambulate. Conservative therapy has included medical management, compression garments, physical therapy and attempted weight loss without an improvement in her function. Photographs show a condition of the lower extremities consistent with lipedema, with a predictable pattern of enlarged lower extremities with sparing of the feet and distal portion of the legs.
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Overturned
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Medical Necessity
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Summary Reviewer
A 19-year-old female enrollee has requested authorization and coverage for liposuction, CPT code 15879 (suction assisted lipectomy of the lower extremity) and 38999 (unlisted procedure hemic or lymphatic system). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees lipedema. The physician reviewer found that the patient has well documented evidence of chronic, painful lipedema of the lower extremities that is affecting her ability to ambulate. Conservative therapy has included medical management, compression garments, physical therapy and attempted weight loss without an improvement in her function. Photographs show a condition of the lower extremities consistent with lipedema, with a predictable pattern of enlarged lower extremities with sparing of the feet and distal portion of the legs. Liposuction is a well-known therapy for lipodystrophy and has been shown to provide possible functional improvement in lipedema. Warren and colleagues noted, Lymphedema and lipedema, two related but distinct disorders leading to lower extremity swelling, have unique clinical features and findings on diagnostic testing and should be excluded as possible causes. Surgical therapy has traditionally involved surgical debulking procedures, which have shown varied postoperative outcomes, although reports using suction lipectomy have been more promising. From Schmeller and colleagues, they note Tumescent liposuction is a highly effective treatment for lipedema with good morphological and functional long-term results. Overall, from review of the medical documentation and relevant medical literature, the patient has a well-recognized condition of lipedema significantly affecting her function that has failed treatment with reasonable conservative measures. Additionally, her photographs are consistent with the overall clinical scenario. Multiple providers, other than the requesting surgeon, have provided supporting documentation for her surgical treatment. Liposuction is well known to be very effective in removing fatty tissue and can be safe and effective. In this case, the patients diagnosis confirms the presence of diseased fatty accumulation which is well documented to be adversely affecting her function. Although liposuction is generally considered a cosmetic intervention, in this case, there is functional impairment that is being addressed. She has failed conservative management and there is no other service available that would likely have a beneficial effect. Thus, as no other treatment appears reasonable to provide possible functional improvement, liposuction of the lower extremities is medically indicated. This is consistent with peer reviewed literature as documented above. Based on the overall clinical documentation for this patient, CPT code 15879 (suction assisted lipectomy of the lower extremity) is medically necessary for treatment of this patients medical condition. However, CPT code 38999, (an unlisted hemic or lymphatic system procedure) is not medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, a portion of the requested services is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
| 1 |
A 69-year-old female enrollee has requested reimbursement for Guardant 360 testing
performed on 1/11/21. The Health Insurer has denied this request and reported that the
services at issue were investigational for the evaluation of the enrollees medical condition.
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Overturned
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Experimental
|
Summary Reviewer 1
A 69-year-old female enrollee has requested reimbursement for Guardant 360 testing
performed on 1/11/21. 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 the integration of plasma next generation sequencing (NGS)
testing into the routine management of stage IV non-small cell lung cancer demonstrates a
marked increase of the detection of therapeutically targetable mutations and improved
delivery of molecularly guided therapy. This is recommended by the National Comprehensive
Cancer Network (NCCN) if there is insufficient tissue for NGS from tumor. Per the NCCN, The
use of cell-free/circulating tumor DNA testing can be considered in specific clinical
circumstances, most notably: if a patient is medically unfit for invasive tissue sampling; in the
initial diagnostic setting, if following pathologic confirmation of a non-small cell lung cancer
diagnosis there is insufficient material for molecular analysis, cell-free/circulating tumor DNA
should be used only if follow-up tissue-based analysis is planned for all patients in which an
oncogenic driver is not identified; in the initial diagnostic setting, if tissue-based testing does
not completely assess all recommended biomarkers owing to tissue quantity or testing
methodologies available, consider repeat biopsy and/or cell-free circulating tumor DNA
testing. In this patients case, the Guardant 360 requisition noted that tissue-based
comprehensive genomic profiling from a recent biopsy was not feasible. Thus, there is sufficient
support for the services at issue in this clinical setting. Therefore, Guardant 360 testing
performed on 1/11/21 was likely to have been more beneficial than other methods of
evaluating this patient.
| 0 |
patient is a 61-year-old female who presented to her provider on 5/25/21 with a complaint of worsening knee pain. The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee.
that the patient has had four weeks of prior physical therapy as well as supervised home exercise program within the prior three months.
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Upheld
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Medical Necessity
|
Summary Reviewer
The patient is a 61-year-old female who presented to her provider on 5/25/21 with a complaint of worsening knee pain. The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee. The physician reviewer found that the current medical evidence does not support the requested services in this clinical setting. The incidence of abnormal MRI findings in asymptomatic individuals was established as early as 1992 by Boden and colleagues. The authors noted, aThe high incidence of abnormal MRI findings in asymptomatic subjects underscores the danger of relying on a diagnostic test without careful correlation with clinical signs and symptoms.a In other words, simply obtaining an MRI without correlation with a detailed clinical examination can lead to unnecessary conclusions, and even worse, unnecessary surgery. For this reason, conservative management, as suggested by the Health Insurer, is certainly worthwhile. In the requisition for the knee MRI, it is stated that the patient has had four weeks of prior physical therapy as well as supervised home exercise program within the prior three months. However, the records do not document this. The submitted documentation does not demonstrate that the patient has completed an appropriate course of conservative management. The records do not document that the patient actually underwent physical therapy. Absent this documentation, the medical necessity of the requested services cannot be established. Therefore, the requested MRI of the left knee is not medically necessary for the evaluation of this patient.
| 1 |
A 61-year-old male enrollee has requested authorization and coverage for positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition.
the patient has a rapidly rising prostate-specific antigen level after radical prostatectomy, and there
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Overturned
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Experimental
|
Summary Reviewer 2
A 61-year-old male enrollee has requested authorization and coverage for positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the patient has a rapidly rising prostate-specific antigen level after radical prostatectomy, and there were inconsistencies on imaging. It has been extensively shown that sodium fluoride positron emission tomography/computed tomography (PET/CT) is a sensitive means with which to detect boney metastases, and this modality would provide the best assessment for the extent of metastatic disease. As the most sensitive bone scanning agent available, this requested technique would be the best way to analyze the equivocal findings. In sum, the requested PET scan is likely to be superior over 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.
| 1 |
The parent of a 12-year-old male enrollee has requested authorization and coverage for Remicade 400 mg for two weeks and then once monthly for one year. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees juvenile dermatomyositis (JDMS).
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Overturned
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Experimental
|
Summary Reviewer 2
The parent of a 12-year-old male enrollee has requested authorization and coverage for Remicade 400 mg for two weeks and then once monthly for one year. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees juvenile dermatomyositis (JDMS). The physician reviewer found in this case, the patients current treatment consists of two oral disease modifying agents, CellCept and methotrexate for a diagnosis of juvenile dermatomyositis. The documentation submitted for review fails to provide supporting evidence of active disease at this time. There is a lack of evidence demonstrating active vasculitis or active inflammatory muscle disease. On the basis of this lack of documentation, escalation of therapy with an additional agent is not warranted and Remicade is not clinically indicated. As such, the request for Remicade is not likely to be more beneficial than other modalities. 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.
| 1 |
A 63-year-old female enrollee has requested reimbursement of liquid CDx laboratory testing by
FoundationOne on 4/29/22. The Health Insurer has denied this request and reported that the service
at issue was investigational for the evaluation of the enrollees lung cancer.
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Overturned
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Experimental
|
Summary Reviewer 1
A 63-year-old female enrollee has requested reimbursement of liquid CDx laboratory testing by
FoundationOne on 4/29/22. The Health Insurer has denied this request and reported that the service
at issue was investigational for the evaluation of the enrollees lung cancer. At issue is whether
CDx laboratory testing by FoundationOne on 4/29/22 was likely to have been more beneficial for
evaluation of the enrollee's condition than any available standard therapy. The physician reviewer
found that the National Comprehensive Cancer Network (NCCN) guidelines for the treatment of
non-small cell lung cancer (NSCLC) note that there is growing recognition of the molecular
mechanisms of resistance to therapy. Retesting a sample from a tumor that is actively progressing
while exposed to targeted therapy can shed light on appropriate next therapeutic steps. Broad
genomic profiling may be the most informative approach to examining potential mechanisms of
resistance, which may require more than one instance of such profiling over the course of an
individual patients therapy. While liquid biopsy should not be used in lieu of tissue-based testing,
Rolfo and colleagues note that isolation and analysis of circulating cell-free tumor
deoxyribonucleic acid (DNA) in plasma is a powerful tool with considerable potential to improve
clinical outcomes across multiple cancer types, including NSCLC. Cell-free tumor DNA testing
generally has very high specificity. While it may also have significantly compromised sensitivity,
with up to a 30% false-negative rate, current medical literature supports complementary testing to
reduce turnaround time and increase the yield of targetable alteration detection. This is especially
true with procedures that typically have a low yield of tissue such as endobronchial ultrasound
(EBUS). Therefore, the service at issue was likely to have been more beneficial for treatment of
the patients medical condition than standard therapy with tissue-based testing alone. Therefore,
CDx laboratory testing by FoundationOne on 4/29/22 was likely to have been more beneficial for
evaluation of the patients condition than any available standard therapy.
| 0 |
A 64-year-old male enrollee has requested authorization and coverage for Privigen. 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.
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Overturned
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Medical Necessity
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Summary Reviewer
A 64-year-old male enrollee has requested authorization and coverage for Privigen. 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 the submitted documentation supports the medical necessity of the requested medication. Patients with myasthenia gravis can have weakness of the ocular, limb, respiratory, and bulbar muscles. The nature of the pathogenesis and the anatomical target can create clinical situations that are very diverse. The clinical presentation can range from mild symptomatology with mild weakness or cosmetic changes to severe life-threatening clinical scenarios involving difficulty with breathing, ambulating, eating, and speaking. The treatment of myasthenia gravis is dependent on several factors, including the patients medical comorbidity, age, involvement of respiratory or bulbar muscles, progression and severity. IVIG is considered a safe and effective tool in the maintenance and acute management of myasthenia gravis. Therefore, Privigen is medically necessary for the treatment of this patient.
| 0 |
A 59-year-old female enrollee has requested reimbursement for the computed tomography (CT) scan performed on 11/17/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees risk of coronary artery disease.
the patient is a 59-year-old female with increased coronary risk but
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Upheld
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Experimental
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Summary Reviewer 3
A 59-year-old female enrollee has requested reimbursement for the computed tomography (CT) scan performed on 11/17/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees risk of coronary artery disease. The physician reviewer found that based on the records provided for review, the patient is a 59-year-old female with increased coronary risk but no documented symptoms or objective findings concerning for coronary ischemia. In this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including screening coronary CT scanning. Treatment change or addition based on the results of screening with coronary CT scanning has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Therefore, the CT scan performed on 11/17/16 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 diagnostic procedure 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 50-year-old female enrollee has requested reimbursement for inpatient admission from 9/21/15 through 9/22/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition.
This patients symptoms had resolved prior to admission. Her vital signs were stable at the time of admission, and the physical examination did not show signs of congestive heart failure or arrhythmia. The initial troponin level was normal.
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Upheld
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Medical Necessity
|
Summary Reviewer
A 50-year-old female enrollee has requested reimbursement for inpatient admission from 9/21/15 through 9/22/15. 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 submitted documentation fails to demonstrate the medical necessity of the services at issue. This patients symptoms had resolved prior to admission. Her vital signs were stable at the time of admission, and the physical examination did not show signs of congestive heart failure or arrhythmia. The initial troponin level was normal. In addition, the provider documentation did not include any reasoning for assignment of the inpatient status. The treatment ordered did not include intravenous nitroglycerin or acute anticoagulation. Urgent cardiac catheterization was not recommended or performed. All of the ordered services were of the intensity that could have been safely provided at the observation level. Had any complication or problem occurred, or the subsequent testing indicated myocardial ischemia, the patient could have appropriately been converted to inpatient status at that time. All told, inpatient admission from 9/21/15 through 9/22/15 was not medically indicated 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 |
A 49-year-old female enrollee has requested reimbursement for endometrial ablation performed on 9/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition.
The records note a history of heavy menstrual bleeding. This patient has opted for a minimally invasive option to control her bleeding. She has opted for an endometrial ablation.
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Upheld
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Experimental
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Summary Reviewer 2
A 49-year-old female enrollee has requested reimbursement for endometrial ablation performed on 9/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the services at issue in this patientas case. The records note a history of heavy menstrual bleeding. This patient has opted for a minimally invasive option to control her bleeding. She has opted for an endometrial ablation. Minimally invasive treatment for heavy bleeding is encouraged in order to avoid more invasive treatment, such as hysterectomy. The current medical evidence supports an endometrial ablation in this clinical setting. The services at issue were likely to benefit the patient, with improved quality of life with decreased menstrual bleeding. Therefore, endometrial ablation performed on 9/23/20 was likely to have been more beneficial than other available standard therapy.
| 1 |
A 38-year-old male enrollee has requested reimbursement for physical therapy provided from 2/16/15 through 3/16/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees status post right knee arthroscopy and right hip arthroplasty.
, the patient had already received extensive therapy prior to surgery with similar therapeutic content. His surgery was uncomplicated.
He had reached a plateau with the treatments already provided and
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Upheld
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Medical Necessity
|
Summary Reviewer
A 38-year-old male enrollee has requested reimbursement for physical therapy provided from 2/16/15 through 3/16/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees status post right knee arthroscopy and right hip arthroplasty. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the services at issue. According to the documentation submitted for review, the patient had already received extensive therapy prior to surgery with similar therapeutic content. His surgery was uncomplicated. Additionally, at least partial concurrent care would be expected after both surgeries. He had reached a plateau with the treatments already provided and an independent home exercise program could have met his needs without ongoing skilled physical therapy oversight. An independent exercise program could have been performed as often as needed rather than during scheduled therapy visits. All told, the physical therapy provided from 2/16/15 through 3/16/15 was not medically necessary in this clinical setting. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
A 21-year-old female enrollee has requested authorization and coverage for inpatient upper jaw surgery. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees midface retrusion and class III malocclusion.
, the patient has evidence of class III malocclusion, maxillary retrusion and hyponasal speech. Cleft palate patients with maxillary retrusion have significant sleep apnea from malposition of the maxilla. This produces obstruction in the nasal airway, the nasopharynx, and velum.
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Overturned
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Medical Necessity
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Summary Reviewer
A 21-year-old female enrollee has requested authorization and coverage for inpatient upper jaw surgery. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees midface retrusion and class III malocclusion. The physician reviewer found that according to the documentation submitted for review, the patient has evidence of class III malocclusion, maxillary retrusion and hyponasal speech. Cleft palate patients with maxillary retrusion have significant sleep apnea from malposition of the maxilla. This produces obstruction in the nasal airway, the nasopharynx, and velum. This demonstrated with hyponasal speech such as the patient in this case. Orthognathic surgery for this patient is medically necessary for correction of the nasal airway obstruction and sleep apnea that results from maxillary retrusion. Moreover, LeFort 1 surgery will move the maxilla forward and give the patient improved speech, improved nasal breathing and relief from sleep apnea and secondary consequences of sleep apnea. Based on the medical documentation provided for review, the request for inpatient upper jaw surgery has been established as medically necessary for treatment of the patients medical condition. Therefore, the requested surgery is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| 1 |
The patient is a 52-year-old male who has a history of chronic low back pain. The patient has requested authorization and coverage for an MRI. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient.
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Upheld
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Medical Necessity
|
Summary Reviewer
The patient is a 52-year-old male who has a history of chronic low back pain. The patient has requested authorization and coverage for an MRI. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. The physician reviewer found that when to obtain specialized cross-sectional imaging of the spine is a difficult decision. Pain is a very common complaint, and not everyone who has pain needs a computed tomography (CT) or MRI scan. As a fundamental principle, an imaging study should affect the management of the patient. In this patientas case, although his pain may be significant, a more conservative management would be optimal at this point, at least until it is proven that a conservative approach is unsuccessful, and surgery or interventions should be deferred until absolutely necessary. At this point, it is unclear whether plain x-rays are warranted. This is not to say that plain x-rays might not provide some information, but the possible finding of degenerative change on plain x-rays would also not change the immediate management. As has been shown in multiple studies, incidental finding of degenerative disease or disc abnormality is exceedingly common in asymptomatic individuals. It is well known that some patients with substantial MRI findings will not have symptoms, and conversely, some patients with minimal signs on MRI will have pronounced symptoms. The American College of Radiology (ACR) has established aAppropriateness Criteriaa to help referring physicians obtain efficient use of imaging modalities to evaluate various clinical presentations. The ACR has established these criteria for chronic neck and low back pain. MRI is felt to be anot usually appropriatea in the management of chronic pain without other red flags. On physical examination, other than the pain, there is no submitted information regarding loss of strength or loss of reflexes or other symptoms, such as incontinence. There is no evidence of prior tumor or infection. While it is always possible that random testing of any organ will demonstrate a significant finding, the likelihood is slim. Based on the submitted records, a lumbar spine MRI is not medically indicated. Therefore, the requested MRI is not medically necessary for the evaluation of this patient.
| 1 |
A 64-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/1/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.
In this case, the patients breasts were described as heterogeneously dense.
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Overturned
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Experimental
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Summary Reviewer 3
A 64-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/1/16. 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 tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patients 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 enables the possibility of demonstrating an otherwise occult tumor. Therefore, the breast tomosynthesis performed on 2/1/16 were 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.
| 1 |
A 39-year-old male enrollee has requested reimbursement for the Factor V Leiden genetic testing and homocysteine testing provided on 3/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees superficial vein thrombophlebitis.
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Overturned
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Experimental
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Summary Reviewer 1
A 39-year-old male enrollee has requested reimbursement for the Factor V Leiden genetic testing and homocysteine testing provided on 3/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees superficial vein thrombophlebitis. The physician reviewer found that most experts recommend testing for the five major inherited hypercoagulable risk factors including protein S, C, and antithrombin deficiencies, factor V Leiden and prothrombin gene mutation as well as for anti-phospholipid syndrome in patients less than age 45. However, testing for homocysteine levels and mutational analysis for the responsible gene, methylene tetrahydrofolate reductase (MTHFR), is not routinely recommended. Although elevated levels of homocysteine can be found in patients with thrombosis, the causal role of hyperhomocysteinemia in thrombosis remains unclear. In addition, lowering homocysteine levels with folic acid, pyridoxine, and vitamin B12 does not appear to reduce the rate of VTE in patients with hyperhomocysteinemia. Thus, Factor V Leiden is supported as beneficial, while homocysteine testing is not likely to be more beneficial. Accordingly, the Factor V Leiden genetic testing provided on 3/23/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the homocysteine testing performed on 3/23/16 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, a portion of 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 partially overturned.
| 1 |
A 54-year-old male enrollee has requested authorization and coverage for Gilotrif (afatinib dimaleate tablet 40 mg). The Health Insurer indicates that the requested medication is investigational for the treatment of the enrollees medical condition. Therefore, the Health Insurer has denied coverage for the requested medication.
This patient was found to have an EGFR mutation after initial therapy with progression.
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Overturned
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Experimental
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Summary Reviewer 1
A 54-year-old male enrollee has requested authorization and coverage for Gilotrif (afatinib dimaleate tablet 40 mg). The Health Insurer indicates that the requested medication is investigational for the treatment of the enrollees medical condition. Therefore, the Health Insurer has denied coverage for the requested medication.
At issue is whether the requested medication is likely to be more beneficial for treatment of the enrollees condition than any available standard therapy. The physician reviewer found that the current medical evidenced supports the requested medication in this clinical setting. This patient was found to have an EGFR mutation after initial therapy with progression. Therapy at this juncture could be considered first-line therapy for the now known EGFR mutation. Afatinib has been approved by the U.S. Food and Drug Administration as first-line therapy for EGFR positive disease. Therefore, Gilotrif (afatinib dimaleate tablet 40 mg) is likely to be more beneficial than other available standard therapy.
| 1 |
A 45-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 2/6/15. 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 patient is a 45-year-old female who underwent routine screening mammogram with computer-aided detection and digital breast tomosynthesis on 2/6/15. The mammogram revealed dense breasts, but was negative and unchanged compared with prior exams. The patient is requesting reimbursement for the breast tomosynthesis performed on 2/6/15. The Health Insurer has denied this request as investigational.T
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Overturned
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Experimental
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Summary Reviewer 1
A 45-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 2/6/15. 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 patient is a 45-year-old female who underwent routine screening mammogram with computer-aided detection and digital breast tomosynthesis on 2/6/15. The mammogram revealed dense breasts, but was negative and unchanged compared with prior exams. The patient is requesting reimbursement for the breast tomosynthesis performed on 2/6/15. The Health Insurer has denied this request as investigational.There is a lack of peer-reviewed literature that supports the use of three-dimensional (3D) breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in the peer-reviewed literature. Thus, the breast tomosynthesis performed on 2/6/15 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 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 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition.
.a This patient presented with a history of right medial meniscus tear and a significant loose body in the lateral gutter, resulting in mechanical locking. She had arthritic changes in the knee for which an arthroplasty might be indicated. However, her primary concern was mechanical locking. Surgery was performed on 8/16/19 to include right knee arthroscopy with partial medial meniscectomy, removal of a large intra-articular body, and abrasion
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Upheld
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Experimental
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Summary Reviewer 1
A 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the services at issue in this patientas case. Beckmann and colleagues concluded that their results asupport the clinical application of arthroscopic arthroplasty as a procedure that enhances cartilage repair as an alternative to far more complex procedures that have gained popularity. Furthermore, the data presented supports clinical investigations that recommend not to use suction drainage as by this procedure a considerable amount of the regeneratory potential of postoperative joint effusions might be extracted.a Lubowitz concluded, aArthroscopic abrasion arthroplasty results in a positive outcome in 66% of patients, and may still merit consideration as a salvage procedure.a This patient presented with a history of right medial meniscus tear and a significant loose body in the lateral gutter, resulting in mechanical locking. She had arthritic changes in the knee for which an arthroplasty might be indicated. However, her primary concern was mechanical locking. Surgery was performed on 8/16/19 to include right knee arthroscopy with partial medial meniscectomy, removal of a large intra-articular body, and abrasion chondroplasty for to the undersurface of the patella for grade III and IV chondral wear. Current evidence-based medical literature supports the inclusion of abrasion chondroplasty (CPT code 29879) during concurrent medial meniscectomy and loose body removal for mechanical locking and to potentially delay total knee replacement given her relatively young age and documented grade III to IV chondral wear. Therefore, arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19 was likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
| 1 |
The parent of a one-year-old male enrollee has requested reimbursement for inpatient services (neonatal care level 3) provided on 8/19/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who had a history of tachypnea.
that while the patient was not feeding well, with intermittent tachypnea, he was overall hemodynamically stable with no need for assisted ventilation. He was on room air, had improving feeding, and was afebrile. His laboratory tests were concerning, but ultimately cultures were negative. He was intermittently tachypneic, but his chest x-ray was consistent with transient tachypnea of the newborn, and he was slowly improving.
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Upheld
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Medical Necessity
|
Summary Reviewer
The parent of a one-year-old male enrollee has requested reimbursement for inpatient services (neonatal care level 3) provided on 8/19/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who had a history of tachypnea. The physician reviewer found that while the patient was not feeding well, with intermittent tachypnea, he was overall hemodynamically stable with no need for assisted ventilation. He was on room air, had improving feeding, and was afebrile. His laboratory tests were concerning, but ultimately cultures were negative. He was intermittently tachypneic, but his chest x-ray was consistent with transient tachypnea of the newborn, and he was slowly improving. It was reasonable and appropriate to pursue evaluation for infection in this case. It was also reasonable to monitor the patient at a level of care higher than the newborn nursery. However, he was not critically ill. He could have been safely and appropriately managed at a lower level of care such as Special Care Nursery, level II. Thus, inpatient services (neonatal care level 3) provided on 8/19/17 was 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 |
A 57-year-old male enrollee has requested reimbursement for electromagnetic navigational bronchoscopy performed on 9/29/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung nodule.T
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Overturned
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Experimental
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Summary Reviewer 1
A 57-year-old male enrollee has requested reimbursement for electromagnetic navigational bronchoscopy performed on 9/29/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung nodule.The physician reviewer found there is a lack of support for the services at issue in this patients case. The medical evidence does not demonstrate that the use of the electromagnetic navigational system improves long-term health outcomes. The services at issue were not standard of care. There are numerous ways of work-up of potential malignant lung disease, including needle biopsy under fluoroscopy, mediastinoscopy, washing, brushing, and positron emission tomography (PET) scan and/or CT scan follow-up. Therefore, electromagnetic navigational bronchoscopy performed on 9/29/15 was not 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 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 64-year-old male enrollee has requested reimbursement for magnetic resonance imaging of the pelvis performed on 3/1/17. The Health Insurer has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollee who has a history of hemorrhoidectomy and elevated prostate specific antigen (PSA).
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Overturned
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Medical Necessity
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Summary Reviewer
A 64-year-old male enrollee has requested reimbursement for magnetic resonance imaging of the pelvis performed on 3/1/17. The Health Insurer has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollee who has a history of hemorrhoidectomy and elevated prostate specific antigen (PSA). The physician reviewer found that the medical literature supports the medical necessity of the service at issue in this clinical setting. In this patient, the PSA levels are borderline, and more importance is being paid to the trend in values over the last several tests. The question is whether to proceed with a biopsy, and the provider is asking for an MRI to assist in that decision. MRI has become a common imaging procedure to better evaluate the prostate. A well-known prostate researcher, Siddiqui has written, targeted MRI/ultrasound fusion biopsy, compared with standard extended-sextant ultrasound-guided biopsy, was associated with increased detection of high-risk prostate cancer and decreased detection of low-risk prostate cancer, (Siddiqui, p. 390). Current National Comprehensive Cancer Network (NCCN) guidelines state that MRI is not recommended routinely prior to initial prostate biopsy, but emerging data suggest that, in men undergoing initial biopsy, targeting using MRI/ultrasound fusion may increase the detection of clinically significant, higher-risk (Gleason grade > or equal to 4 + 3=7) disease while lowering the detection of lower-risk (Gleason sum 6 or lower-volume Gleason 3 + 4=7) disease. Consequently, for this patient, if the patient does not have suspicious findings on multiparametric MRI, there is only a 3% chance of detecting a clinically significant cancer, whereas if the MRI has suspicious findings, then a biopsy could be warranted. Based on the medical research, multiparametric MRI was useful for this patient, and may have helped him avoid life-altering complications that could occur with unnecessary surgery. MRI of the pelvis performed on 3/1/17 was medically necessary for the evaluation of this patients medical condition. Therefore, for the reasons stated above, the service at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
| 1 |
The patient is a 49-year-old female. The patient has requested reimbursement for physiotherapy
services from 11/22/21 through 8/5/22. The Health Insurer has denied this request and reported
that the services at issue were not medically necessary for the treatment of this patient.
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Overturned
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Medical Necessity
|
Summary Reviewer
The patient is a 49-year-old female. The patient has requested reimbursement for physiotherapy
services from 11/22/21 through 8/5/22. 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 submitted documentation supports the medical necessity of a
portion of the services at issue. The treatment of chronic pain has been extensively studied and
reviewed in medical literature over the past few decades. Emphasis has been placed on
minimizing disability, avoiding opiate use in most cases, and using complimentary medicine when
a benefit can be shown. Physical therapy is expected to emphasize goal focused disability
reduction through education and exercise aided by modalities such as heat, ultrasound, or aqua
therapies. Chiropractic spinal manipulation in relation to chronic pain focuses on symptom
reduction and well-being. Goertz and colleagues report that chiropractic care, when added to
usual medical care, resulted in moderate short-term improvements in low back pain intensity
and disability. Qassem and colleagues note that American College of Physician (ACP) guidelines
regarding noninvasive treatments for acute, subacute, and chronic low back pain support trials
of complementary medicine across the domains of acupuncture, chiropractic, or exercise for
musculoskeletal pain. While the progression from acupuncture to physical therapy to chiropractic
was appropriate, the records did not document benefits, save for headache reduction in physical
therapy, in almost 18 months of treatment. In this clinical setting, given that the patient has tried
and failed other modalities of therapy including physical therapy, acupuncture, and medication
management, current medical literature supports six chiropractic sessions at a minimum prior to
seeing benefit. Therefore, six sessions of physiotherapy services from 11/22/21 through 8/5/22
were medically necessary for the treatment of this patient.
| 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.
The patient felt isolated and limited in her pursuit of quality of life activities in caring for her husband. However, she did have a supportive brother and was motivated for treatment.
. The patient was seeing a psychiatrist in the community, but the extent of non-pharmacologic interventions, including respite care, was not reported. Further, the patient was not seeing a psychologist or therapist at the time of admission.
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Upheld
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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 that the residential mental health services provided from 4/6/15 through 5/5/15 were not medically necessary for treatment of the patients medical condition. The documentation submitted for review does not support the initial residential placement. The patient felt isolated and limited in her pursuit of quality of life activities in caring for her husband. However, she did have a supportive brother and was motivated for treatment. Although formidable in its persistence and intensity, there was no mention of a change in the symptom complex. The patient was seeing a psychiatrist in the community, but the extent of non-pharmacologic interventions, including respite care, was not reported. Further, the patient was not seeing a psychologist or therapist at the time of admission. Finally, the patient had not failed a less restrictive treatment setting, such as partial hospitalization or an intensive outpatient program, during this episode of illness. This is significant in this case for two reasons: first, current psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment; second, there was no evidence to suggest that a less restrictive treatment setting would have been insufficient. Thus, the residential mental health services at issue were not medically necessary for treatment of the patients behavioral health 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 50-year-old female enrollee has requested authorization and coverage for Balversa 4 mg
tablets (two tablets per day). The Health Insurer has denied this request indicating that the
requested medication is considered investigational for treatment of the insureds urothelial
carcinoma.
, this patient
presents with metastatic lung cancer with metastases to brain, liver, and bone. The patient has
been treated with Tagrisso plus Balversa therapy with improvement of her condition. The
provider has recommended continuation of this therapeutic regimen.
. The patient was noted to have pneumonitis increasing the risk of recurrence
with immunotherapy.
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Overturned
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Experimental
|
Summary Reviewer 1
A 50-year-old female enrollee has requested authorization and coverage for Balversa 4 mg
tablets (two tablets per day). The Health Insurer has denied this request indicating that the
requested medication is considered investigational for treatment of the insureds urothelial
carcinoma. The physician reviewer found that as noted in the medical records, this patient
presents with metastatic lung cancer with metastases to brain, liver, and bone. The patient has
been treated with Tagrisso plus Balversa therapy with improvement of her condition. The
provider has recommended continuation of this therapeutic regimen. As noted in the medical
literature, patients with EGFR mutations with initial responses to osimertinib have been able to
overcome resistance with the addition of Balversa both in vitro and in small case reports. This
patient is not listed as having positive PDL1 or other markers to indicate benefit from
immunotherapy. The patient was noted to have pneumonitis increasing the risk of recurrence
with immunotherapy. There are limited options for treatment after recurrence on osimertinib.
Given this support, the requested Balversa 4 mg tablets (two tablets per day) is likely to be more
beneficial for treatment of the patients medical condition than any available standard therapy.
| 1 |
A 56-year-old male enrollee has requested reimbursement for FoundationOne testing performed on 3/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent myxofibrosarcoma.
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Overturned
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Experimental
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Summary Reviewer 2
A 56-year-old male enrollee has requested reimbursement for FoundationOne testing performed on 3/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent myxofibrosarcoma. The physician reviewer found that this documentation provided supports the efficacy of the services at issue in this clinical setting. Myxofibrosarcoma is a rare cancer that is found to have a very heterogeneous genetic make up. Treatment is difficult due to rarity and lack of established guidelines. Genetic profiling, such as with FoundationOne testing, provides genetic profiling to help guide therapeutic decision making. Accordingly, in this patients case, FoundationOne testing performed on 3/14/17 was likely to have been more effective than the standard methods of evaluating this patients medical condition. 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 54-year-old female enrollee has requested reimbursement for color-flow Doppler echocardiography performed on 3/29/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees chest pain and dyspnea.
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Overturned
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Experimental
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Summary Reviewer 2
A 54-year-old female enrollee has requested reimbursement for color-flow Doppler echocardiography performed on 3/29/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees chest pain and dyspnea. The physician reviewer found that the records document increased coronary risk and symptoms suspicious for coronary ischemia. Overall, the patients pre-test risk based on her risk factors, age and symptoms was at least moderate. In this circumstance, a test with increased sensitivity such as a stress echocardiogram is preferable and appropriate compared to a regular treadmill electrocardiogram with a reduced sensitivity of about only 60 to 70%. In addition, the stress echocardiogram is able to assess for other potential causes of the patients exertional dyspnea, such as cardiomyopathy or occult valvular disease. Current guidelines endorsed by several national organizations also consider stress echocardiogram appropriate in this circumstance. The medical evidence supports the use of color-flow Doppler echocardiography in this patients case. In sum, color-flow Doppler echocardiography performed on 3/29/18 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.
| 1 |
The parent of a five-year-old female enrollee has requested authorization and coverage for therapeutic activities, direct (one on one) patient contact. 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.
this patient has documented difficulties with motor coordination, postural stability, self-regulation, and fine/gross motor skills.
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Overturned
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Medical Necessity
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Summary Reviewer
The parent of a five-year-old female enrollee has requested authorization and coverage for therapeutic activities, direct (one on one) patient contact. 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 this patient has documented difficulties with motor coordination, postural stability, self-regulation, and fine/gross motor skills. With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills, processing information, and regulating the response to incoming information, occupational therapy is an appropriate intervention strategy for this patient. Sensory-based interventions alone have not been demonstrated to be beneficial. However, it may be acceptable to incorporate sensory-based modalities into a comprehensive treatment plan. This patient has challenges that negatively impact her daily functioning, and occupational therapy is appropriate to address these challenges. The submitted documentation supports the requested services in this clinical setting. Therefore, therapeutic activities, direct (one-on-one) patient contact are medically necessary for the treatment of this patient.
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A 40-year-old female enrollee has requested reimbursement for the Decision Dx test and specimen handling provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees cutaneous melanoma.
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Upheld
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Experimental
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Summary Reviewer 3
A 40-year-old female enrollee has requested reimbursement for the Decision Dx test and specimen handling provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by the staging system discussed by Balch and colleagues. Based on this study, a pT1a melanoma has an extremely good prognosis with a very low risk of recurrence. Decision Dx is the study of 31 genes in the melanoma cells and classifies the melanoma as Class 1, with a disease free state of 97% at five years, or Class 2, with a 31% disease free rate at five years. However, it has not been established in the scientific data that the Decision Dx findings can be used reliably to influence decision making in clinical practice. All told, the Decision Dx test and specimen handling provided on 11/23/15 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, 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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