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The patient is a 61-year-old female with a left-sided thyroid nodule. Cytology from a fine needle aspiration biopsy was indeterminate. A specimen was subsequently sent for Afirma gene classifier analysis. The patient has requested reimbursement for the gene test provided on 12/21/16. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of this patient.
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Overturned
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Experimental
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Summary Reviewer 1
The patient is a 61-year-old female with a left-sided thyroid nodule. Cytology from a fine needle aspiration biopsy was indeterminate. A specimen was subsequently sent for Afirma gene classifier analysis. The patient has requested reimbursement for the gene test provided on 12/21/16. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of this patient. While a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. Afirma gene classifier analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby avoiding unnecessary surgeries. Because it is sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Therefore, the gene test provided on 12/21/16 was likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were 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 42-year-old male enrollee has requested reimbursement for decompression procedure performed on 10/5/15. The Health Insurer has denied this request indicating that the procedure at issue is considered investigational for treatment of the enrollees occipital neuralgia.
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Upheld
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Experimental
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Summary Reviewer 3
A 42-year-old male enrollee has requested reimbursement for decompression procedure performed on 10/5/15. The Health Insurer has denied this request indicating that the procedure at issue is considered investigational for treatment of the enrollees occipital neuralgia. The physician reviewer found that occipital neuralgia is a condition characterized by frequent and severe headaches characterized by paroxysmal stabbing pain in the distribution of the greater or lesser occipital nerves. The pain is located in the occipital area and may spread toward the vertex; it is usually unilateral but may be bilateral. The treatment plan for occipital neuralgia depends upon many factors, such as the severity of the dysfunction and pain, the type and location of the pain, as well as patients age, ongoing medical conditions, and ability to tolerate other medical therapies. Standard therapy may include medications to relieve pain and muscle spasms, localized injections, physical therapy, or massage. Surgical release of the greater occipital nerve has been demonstrated to be clinically effective in eliminating or reducing chronic migraine symptoms. However, migraine symptoms in some patients continue after this procedure. It was theorized that a different relationship between the greater occipital nerve and occipital artery may exist in these patients that may be contributing to these outcomes. Vascular pulsation may cause irritation of the nerve and is a possible explanation for migraine headaches that have the occipital region as a trigger point. Future imaging studies and clinical investigation is necessary to further examine the link between anatomy and clinical presentation. At this time, occipital release surgery warrants further investigation. As such, the decompression procedure performed on 10/5/15 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 procedure 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 60-year-old male enrollee has requested reimbursement for inpatient care provided on 11/07/18. 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.
By 11/07/18, the patient had been admitted for two days, but was not yet on a full liquid diet, and still had episodes of hypertension requiring intravenous hydralazine. He had just started having bowel movements and had the nasogastric tube removed the day before.
The patient warranted confirmation that small bowel obstruction had been resolved, bowel function had returned to normal, and that he was
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Overturned
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Medical Necessity
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Summary Reviewer
A 60-year-old male enrollee has requested reimbursement for inpatient care provided on 11/07/18. 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 the submitted documentation supports the medical necessity of the services at issue. By 11/07/18, the patient had been admitted for two days, but was not yet on a full liquid diet, and still had episodes of hypertension requiring intravenous hydralazine. He had just started having bowel movements and had the nasogastric tube removed the day before. In such cases, discharge on 11/06/18 or 11/07/18 would have been premature. The patient warranted confirmation that small bowel obstruction had been resolved, bowel function had returned to normal, and that he was able to tolerate sufficient oral intake to maintain nutrition before discharge, or there would be a high probability of readmission. Therefore, inpatient care provided on 11/07/18 was medically necessary for the treatment of this patient.
| 1 |
A 63-year-old female enrollee has requested reimbursement for Guardant360 testing performed
on 2/04/21. The Health Insurer has denied this request and reported that the services at issue
were investigational for the evaluation of the enrollees medical condition.
, although the patient has a history of breast cancer,
she appears to be in remission as her last documented therapy (2004) was 17 years prior to the
Guardant360 test.
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Upheld
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Experimental
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Summary Reviewer 3
A 63-year-old female enrollee has requested reimbursement for Guardant360 testing performed
on 2/04/21. 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 molecular testing is an important part of testing in breast cancer and can
help direct treatment options. In this case, although the patient has a history of breast cancer,
she appears to be in remission as her last documented therapy (2004) was 17 years prior to the
Guardant360 test. Although the recent imaging studies are concerning for recurrence, there is
no histologic confirmation of her disease. National Comprehensive Cancer Network and
American Society of Clinical Oncology guidelines for metastatic breast cancer recommend a
tissue biopsy to confirm the diagnosis prior to treatment planning. Previous notes had
mentioned BRCA1 positive disease, and so this positive finding on the Guardant360 testing would
not confirm disease recurrence at the present time. Without prior confirmation of recurrent
disease, the Guardant360 test is not more beneficial than standard therapy. Therefore,
Guardant360 testing performed on 2/04/21 was not likely to have been more beneficial than any
available standard therapy.
| 1 |
A 62-year-old female enrollee has requested reimbursement for FoundationOne CDx test performed on 12/31/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition.
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Overturned
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Experimental
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Summary Reviewer 1
A 62-year-old female enrollee has requested reimbursement for FoundationOne CDx test performed on 12/31/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition. The physician reviewer found that a Non-small cell lung cancer, particularly adenocarcinoma, should be tested for a variety of mutations, including EGFR, ALK, ROS-1, KRAS, tumor mutational burden and microsatellite instability. Each of these has therapeutic implications. Ordinarily, these genomic assays are done on the tissue biopsy done for diagnosis. FoundationOne assay is an assay of more than 300 gene mutations, including those noted above. However, beyond the specific mutations noted above, there has been a lack of convincing data that the assays for the rest are of clinical benefit. The chance of benefit from therapy guided by such a general assay is small. Therefore, FoundationOne CDx test performed on 12/31/19 was not likely to have been more beneficial than other available standard therapy.
| 0 |
A 61-year-old female enrollee has requested reimbursement for the molecular profiling lab testing performed on 1/23/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic carcinoma of unknown primary site.
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Upheld
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Experimental
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Summary Reviewer 3
A 61-year-old female enrollee has requested reimbursement for the molecular profiling lab testing performed on 1/23/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic carcinoma of unknown primary site. The physician reviewer found that the determination of a patients primary site of an adenocarcinoma is of clinical importance in determining the most likely treatment to be efficacious. The use of genetic markers is likely to indicate the most likely primary site, and also to help guide treatment determinations (Weiss, et al; Hainsworth, et al). For these reasons, the molecular profiling lab testing performed on 1/23/15 was likely to be of greater clinical benefit than standard available testing. Based upon the information set forth above, I have determined the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| 1 |
The parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services provided from 2/16/16 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 condition.
As of 2/16/16, the patient did not have any suicidal ideation. She did not have any mania, psychosis, or delusions. She was interactive with peers. She was engaged in her treatment and opening up more in group.
The patient scored a two (2) on the risk of harm dimension as the patient had intermittent suicidal ideation without any prior history of suicide attempts. The patient had occasional impulsivity and had brief lapses in the ability to care for herself. The patient scored a two (2) in the functional status dimension as the patient had times where she would fast and/or restrict calories.
the patient was medically compromised or had any hypotensive episodes due to her lack of eating. The patient had no legal trouble, she attended school, and was cooperative with staff. The patient would demonstrate a significant improvement in functioning following a period of deterioration. The patient scored
. The patient would have episodes of elevated anxiety which are
debilitating and would adversely affect the patient. The patient scored a three (3) in the environmental stress dimension. The patient moved to California and had a hard time adjusting. She was a victim of bullying and had frequent adverse interactions with her parents. The patient scored a one (1) in the
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Upheld
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Medical Necessity
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Summary Reviewer
The parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services provided from 2/16/16 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 condition. The physician reviewer found the residential treatment center services provided from 2/16/16 forward were not and are not medically necessary for treatment of the patients medical condition. As of 2/16/16, the patient did not have any suicidal ideation. She did not have any mania, psychosis, or delusions. She was interactive with peers. She was engaged in her treatment and opening up more in group. Utilizing the Child and Adolescent Level of Care Utilization System (CALOCUS), the patients total score is a 15. This score correlates with a recommendation for outpatient treatment. The patient scored a two (2) on the risk of harm dimension as the patient had intermittent suicidal ideation without any prior history of suicide attempts. The patient had occasional impulsivity and had brief lapses in the ability to care for herself. The patient scored a two (2) in the functional status dimension as the patient had times where she would fast and/or restrict calories. However, there was no evidence that the patient was medically compromised or had any hypotensive episodes due to her lack of eating. The patient had no legal trouble, she attended school, and was cooperative with staff. The patient would demonstrate a significant improvement in functioning following a period of deterioration. The patient scored a two (2) in the co-morbidity dimension. The patient would have episodes of elevated anxiety which are moderately debilitating and would adversely affect the patient. The patient scored a three (3) in the environmental stress dimension. The patient moved to California and had a hard time adjusting. She was a victim of bullying and had frequent adverse interactions with her parents. The patient scored a one (1) in the environmental support dimension. Both parents were engaged and invested in the patients recovery and treatment. The patient scores a three (3) in the resiliency dimension. The patient has demonstrated inconsistent or equivocal capacity to deal with stressors, and recovery has been maintained for moderate periods of time, but only with strong professional support. The patient scored a two (2) in the engagement dimension. The patient is able to develop a positive relationship with providers. She passively cooperates in treatment planning and treatment. Given the patients total CALOCUS score of 15, as of 2/16/16, the patient can safely and effectively be treated at a lower level of care. For the reasons provided, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
A 61-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 colorectal cancer with liver metastases.
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Upheld
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Experimental
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Summary Reviewer 2
A 61-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 colorectal cancer with liver metastases. The physician reviewer found that there is no medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for rectal cancer (Allen, et al). There is no data submitted that suggests that treatment with proton techniques will be able to improve sparing of the small bowel compared to standard intensity modulated radiation or three-dimensional (3D) conformal techniques with photons. The National Comprehensive Cancer Network (NCCN) guidelines do not support the use of proton therapy in this clinical setting. In the majority of cases, treatment with photon techniques is advised, especially in the palliative setting. Moreover, there is a lack of level I evidence to support the use of proton therapy for the treatment of rectal cancer. Based on these reasons, the requested proton beam 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 |
A 60-year-old male enrollee has requested reimbursement for positron emission tomography (PET) performed on 3/08/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer.
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Overturned
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Experimental
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Summary Reviewer 2
A 60-year-old male enrollee has requested reimbursement for positron emission tomography (PET) performed on 3/08/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that based on the rising PSA levels, the patient had recurrence of his prostate cancer. Regardless of imaging studies, rising PSA levels in a patient who has had what was felt to be definitive therapy for prostate cancer is unequivocal evidence of recurrence. If the recurrence is local, then this can be treated by external beam radiotherapy. On the other hand, if the patient has distal metastases, the more optimal treatment is likely hormone deprivation therapy. The detection of early recurrence is often difficult. 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. In this patients case, the PET scan detected recurrence not appreciable by other modalities. Thus, PET performed on 3/08/18 was likely to have been superior over other available 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 seven-year-old female enrollee has requested reimbursement for individual psychophysiological therapy incorporating feedback training
psychotherapy services provided from 10/31/14 through 12/9/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees attention-deficit/hyperactivity disorder (ADHD).T
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Upheld
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Experimental
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Summary Reviewer 1
The parent of seven-year-old female enrollee has requested reimbursement for individual psychophysiological therapy incorporating feedback training by any modality with psychotherapy services provided from 10/31/14 through 12/9/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees attention-deficit/hyperactivity disorder (ADHD).The physician reviewer found the services at issue were not likely to be more effective for this patient than any other available options. There is a lack of evidence-based research in the medical literature to support the services at issue. According to the American Academy of Child and Adolescent Psychiatry, It seems established that a pharmacological intervention for ADHD is more effective than a behavioral treatment alone. Additionally, the documentation submitted for review does not mention evidenced-based treatments tried such as parent training or social skills training. All told, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than standard treatment options. The Health Insurers denial should be upheld.
| 1 |
A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.
On 1/09/19, the patients provider noted the off-drug pH study comes back with normal DeMeester scores, and cannot substantiate the diagnosis of significant reflux.
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Upheld
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Experimental
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Summary Reviewer 2
A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that appropriate patient selection is crucial before anti-reflux procedures. On 1/09/19, the patients provider noted the off-drug pH study comes back with normal DeMeester scores, and cannot substantiate the diagnosis of significant reflux. Per the records, upper endoscopy did not document significant reflux esophagitis either. Further, the patient cannot be considered medically refractory to maximally dosed acid suppression. Additionally, the records document significant esophageal dysmotility. The risks, medical appropriateness, or necessity of LINX in the setting of hypertonic esophageal motility disorder is not apparent. In this case, the requested services are not likely to be more beneficial for treatment of the patients medical condition than available standard therapy, such as weight loss, lifestyle modification, further characterization of lower esophageal reflux dysfunction, and maximal proton pump inhibitor use. In sum, the LINX Reflux Management System (code 43284) and one inpatient day are not likely to be of greater benefit than other treatment options.
| 1 |
A 36-year-old male enrollee has requested reimbursement for acute inpatient psychiatric treatment provided from 2/12/16 through 2/23/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition.
himself or others. Although grandiose, he demonstrated no overt psychosis. He did not attest to visual hallucinations or auditory hallucinations. No delusions were apparent, and he was medically stable. He was goal-directed. The patient was cooperative with his medication regimen and tolerated it well. He was deemed to be no elopement risk. During the dates of service in dispute, he
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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 acute inpatient psychiatric treatment provided from 2/12/16 through 2/23/16. 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 was not a threat to himself or others. Although grandiose, he demonstrated no overt psychosis. He did not attest to visual hallucinations or auditory hallucinations. No delusions were apparent, and he was medically stable. He was goal-directed. The patient was cooperative with his medication regimen and tolerated it well. He was deemed to be no elopement risk. During the dates of service in dispute, he no longer required inpatient treatment and could have been treated at a lower level of care. All told, acute inpatient psychiatric treatment provided from 2/12/16 through 2/23/16 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 52-year-old male enrollee has requested authorization and coverage for olaparib (Lynparza) tablet 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees prostate cancer.
This patient did not progress on docetaxel and has not been treated with cabazitaxel.
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Upheld
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Experimental
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Summary Reviewer 2
A 52-year-old male enrollee has requested authorization and coverage for olaparib (Lynparza) tablet 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that the standard of care for prostate cancer includes use of docetaxel or cabazitaxel which have been demonstrated in phase III randomized trials to prolong survival. This patient did not progress on docetaxel and has not been treated with cabazitaxel. Further, additional agents referenced in the National Comprehensive Cancer Network (NCCN) guidelines have greater support for this patients condition than the proposed treatment. Mateo and colleagues reported that Lynparza may provide additional benefit in patients with a BRCA or ATM mutation. However, this patients records document the presence of a FANCA mutation, which has not been shown to increase the effectiveness of Lynparza. For these reasons, the requested Lynparza tablet 100 mg 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 medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 1 |
A 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.
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Overturned
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Experimental
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Summary Reviewer 2
A 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination. The physician reviewer found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, her breasts have been described as extremely 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, digital breast tomosynthesis performed on 9/26/16 was likely to have been of greater benefit than other modalities for evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.]
| 1 |
A 62-year-old male enrollee has requested authorization and coverage for insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.
that this patient has obstructive sleep apnea and has mild septal deviation. A drug-induced sleep endoscopy showed no concentric collapse at velum and complete anterior-posterior collapse at some levels. The patient has not been able to tolerate continuous positive airway pressure therapy. The Inspire
Per the submitted records, this patient is a candidate for the Inspire device, given that he has anterior-posterior collapse at the tongue base.
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Overturned
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Experimental
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Summary Reviewer 1
A 62-year-old male enrollee has requested authorization and coverage for insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has obstructive sleep apnea and has mild septal deviation. A drug-induced sleep endoscopy showed no concentric collapse at velum and complete anterior-posterior collapse at some levels. The patient has not been able to tolerate continuous positive airway pressure therapy. The Inspire device has been approved by the U.S. Food and Drug Administration for the treatment of obstructive sleep apnea. Per the submitted records, this patient is a candidate for the Inspire device, given that he has anterior-posterior collapse at the tongue base. Therefore, insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator is likely to be more effective than other treatment options.
| 1 |
A 62-year-old male enrollee has requested reimbursement for the RT300 functional electrical stimulator (FES) cycle provided on 2/10/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees quadriplegia.
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Upheld
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Experimental
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Summary Reviewer 3
A 62-year-old male enrollee has requested reimbursement for the RT300 functional electrical stimulator (FES) cycle provided on 2/10/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees quadriplegia. The physician reviewer found the RT300 FES is a primary at-home internet linked and remote-clinician monitored intervention for patients with spinal cord injury (SCI) that provides intense electrical stimulation to intact peripheral nerves below the level of the SCI to evoke muscle contractions. Physical activities, like FES, that provide adequate stress to bone, can play a role in the improvement in bone mineral density with the possible prevention or reduction of osteoporosis and a decrease in fractures, two disabling and costly conditions for persons with paralysis due to SCI (Dolbow, et al). In addition, Fazio noted that repeated use of FES can lead to sensorimotor improvements as well as cortical reorganization, changes that cannot be accomplished with passive range of motion alone due to lack of sensory or motor input or activation of motor units, which is essential for motor relearning and neuromuscular reeducation. Thus, the intended in-home use of the RT300 FES cycle will help to remove many of the physical barriers to exercise which is a key factor in promoting regular physical activity in the SCI patient. For these reasons, the RT300 FES cycle provided on 2/10/16 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 equipment at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| 1 |
A 41-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/17/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition.
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Upheld
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Experimental
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Summary Reviewer 2
A 41-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/17/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that various (mostly retrospective) studies of prognostic gene expression profiling (GEP) suggest its role as an independent predictor of worse outcome, although not superior to Breslow thickness or sentinel lymph node biopsy status. It remains unclear whether this GEP profile is reliably
predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models. Therefore, DecisionDx-Melanoma testing performed on 1/17/20 was not likely to have been more beneficial than other methods of evaluating this patient.
| 0 |
A 36-year-old male enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees sleep apnea.
This patients BMI was noted to be 31.9. This patient meets clinical criteria for surgical
of the OSA symptoms and has undergone extensive evaluation of the problems associated with sleep deprivation. This patient has trialed CPAP therapy for airway management with failure to control symptoms of OSA, and was intolerant of CPAP.
this patient has narrowing of the hypopharyngeal and anterior/posterior palatal airway on sleep endoscopy and
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Overturned
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Experimental
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Summary Reviewer 2
A 36-year-old male enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees sleep apnea. The physician reviewer found that the available clinical studies and recent medical evidence demonstrate that implantation of hypoglossal nerve stimulator can be an effective technique in improving this patients symptoms. The American Academy of Otolaryngology Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with CPAP. Woodson and colleagues indicate that patients achieve a definite benefit from the implantation and electrical stimulation of the hypoglossal nerve for treatment of OSA. Clinical studies also recommend that patients benefit from this device when they have a BMI less than 32. This patients BMI was noted to be 31.9. This patient meets clinical criteria for surgical management of the OSA symptoms and has undergone extensive evaluation of the problems associated with sleep deprivation. This patient has trialed CPAP therapy for airway management with failure to control symptoms of OSA, and was intolerant of CPAP. While alternative surgical methods are available, this patient has narrowing of the hypopharyngeal and anterior/posterior palatal airway on sleep endoscopy and meets criteria for the implantation technique. In summary, implantation of hypoglossal nerve stimulator is likely to be more effective for treatment of the patients medical condition than the available alternatives. Therefore, for the reasons stated 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 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/27/16. The Health Insurer has denied this request indicating that the testing at issue is 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 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/27/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational 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 assay should not be used outside of a clinical trial setting. The use of DecisionDx-Melanoma testing is not the standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the patients treatment or health outcome. All told, the DecisionDx-Melanoma testing performed on 10/27/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 1 |
In this case, the patient has an exceptionally rare glioma subtype called pleomorphic
xanthoastrocytoma.
, the patient requires therapy for recurrent disease with a new metastatic
site. The oncologist has prescribed dual BRAF/MEK inhibition in the form of binimetinib and
encora
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Upheld
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Medical Necessity
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Summary Reviewer
The patient is a 52-year-old male with a primary brain tumor. The physician reviewer found that
the submitted documentation does not support the medical necessity of the requested
medication. In this case, the patient has an exceptionally rare glioma subtype called pleomorphic
xanthoastrocytoma. These gliomas have a 60% to 70% prevalence of mutations in BRAF,
particularly the V600E mutation. This clinical situation is also unusual in that the tumor
metastasized outside the cranium. The unusual nature of this clinical situation and the overall
rarity of the tumor means that there is a lack of randomized clinical trials to refer to for supportive
evidence when deciding on treatment strategies. However, current medical literature does
support the safety and efficacy of combined BRAF/MEK inhibition in gliomas, especially the
pleomorphic xanthoastrocytoma subtype. Kata and colleagues report that case series and
literature review indicate that dual-drug therapy with BRAF and MEK inhibitors for recurrent and
anaplastic pleomorphic xanthoastrocytoma with BRAF V600E mutation may delay tumor
progression without unexpected adverse effects. The National Comprehensive Cancer Network
(NCCN) guidelines include BRAF/MEK inhibitors in the treatment of gliomas that are recurrent or
progressive. In this case, the patient requires therapy for recurrent disease with a new metastatic
site. The oncologist has prescribed dual BRAF/MEK inhibition in the form of binimetinib and
encorafenib. However, these inhibitors have only been studied in melanoma, with limited
experience in gliomas. The NCCN guidelines suggest combinations of dabrafenib/trametinib or
vemurafenib/cobimetinib. In this clinical setting, given that the prescribed dual BRAF/MEK
inhibition is not supported by the NCCN guidelines, the requested medication is not medically
indicated. Therefore, Braftovi 75 mg and Mektovi 15 mg are not medically necessary for the
treatment of this patient.
| 1 |
A 48-year-old male enrollee has requested reimbursement for polymerase chain reaction (PCR) testing performed on 7/15/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.
, the patient presents with fatigue of intermittent duration over several years. The exam findings
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Upheld
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Experimental
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Summary Reviewer 1
A 48-year-old male enrollee has requested reimbursement for polymerase chain reaction (PCR) testing performed on 7/15/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that in this case, the patient presents with fatigue of intermittent duration over several years. The exam findings are unremarkable. The laboratory studies are normal or negative. The records submitted for review do not demonstrate a diagnosis of Lyme disease. He has had negative IgG and IgM serologic assays. Acute Lyme disease may have IgM positivity and late stage Lyme disease has IgG positivity. The medical records submitted fail to provide a clinical indication for PCR testing in the presence of a negative serology. Moreover, there is a lack of evidence demonstrating the presence of either early or late stage Lyme disease. Accordingly, the PCR testing performed on 7/15/15 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 |
A 43-year-old female enrollee has requested authorization and coverage for endovenous ablation. 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 symptomatic left great saphenous vein reflux. The vein measures 5.2 mm, and there is reflux of 2 seconds.
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Overturned
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Medical Necessity
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Summary Reviewer
A 43-year-old female enrollee has requested authorization and coverage for endovenous ablation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has symptomatic left great saphenous vein reflux. The vein measures 5.2 mm, and there is reflux of 2 seconds. The clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum recommend a cutoff value of 1 second for abnormally reversed flow (reflux) in the femoral and popliteal veins and of 500 ms for the great saphenous vein, the small saphenous vein, the tibial, deep femoral, and the perforating veins. The current medical evidence supports the requested services in this clinical setting. Therefore, endovenous ablation is medically necessary for the treatment of this patient.
| 1 |
A 38-year-old male enrollee has requested reimbursement for genetic testing performed on 5/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.
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Overturned
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Experimental
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Summary Reviewer 2
A 38-year-old male enrollee has requested reimbursement for genetic testing performed on 5/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that molecular testing has emerged as a promising method for clarifying the gray area of indeterminate thyroid fine needle aspirations, with the aim of reducing the overtreatment of benign nodules and increasing the preoperative detection of malignant nodules that should be treated by a single surgery (total thyroidectomy) rather than a two-step procedure. When molecular testing informs patient management, it should be further integrated with clinical findings and ultrasonographic results. As additional information accumulates to further refine these integrated approaches to patient management, the genetic information provided by molecular tests is expected to increasingly individualize the management of patients with thyroid nodules and cancer. In this patients case, a second thyroid biopsy was not necessary because this test was done as a follow-up of an indeterminate result. A benign result by the ThyGenX/ThyraMIR test has a significant negative predictive value. The medical evidence supports the services at issue in this clinical setting. All told, genetic testing performed on 5/31/18 was likely to have been more beneficial than other methods of evaluating this patient.
| 0 |
The patient is a 35-year-old male who was admitted on 9/17/18. The records noted acute psychosis due to auditory hallucinations, disorganized behavior, and homicidal threats toward his parents, whom he was living with.
auditory hallucinations, paranoia and delusions. His ability to decompensate due to noncompliance remained high.
due to inability to provide for basic needs due to his symptoms. His comorbidity dimension was scored a 2. He had severe mental illness.
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Overturned
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Medical Necessity
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Summary Reviewer
The patient is a 35-year-old male who was admitted on 9/17/18. The records noted acute psychosis due to auditory hallucinations, disorganized behavior, and homicidal threats toward his parents, whom he was living with. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. With regard to risk of harm, the records support a score of 5 due to homicidal ideation, auditory hallucinations, paranoia and delusions. His ability to decompensate due to noncompliance remained high. In terms of functional status, the records support a score of 5 due to inability to provide for basic needs due to his symptoms. His comorbidity dimension was scored a 2. He had severe mental illness. Due to lack of cooperation with medical staff, other medical conditions were difficult to determine. In terms of level of stress of the recovery environment, the records support a score of 4 due to lack of employment, housing, and inability to manage his day-to-day life. With regard to level of support of the recovery environment, the records support a score of a 3. The records noted involvement of parents and other agencies to help him, but a lack of connection to friends or employers. In terms of treatment history, the records support a score of 4 due to multiple hospitalizations, multiple treatments that failed due to noncompliance due to symptoms of schizophrenia. With regard to engagement, the records support a score of 5 due to refusal to take vital signs, take blood draws, and refusal to participate in group and individual therapy. Therefore, the records support a score of 28. The records support inpatient hospitalization in the patients case. Thus, inpatient behavioral health services provided from 10/01/18 through 11/12/18 were medically necessary for the treatment of this patient.
| 1 |
patient is a 50-year-old male who presented with onset of lumbar radiculopathy. The patient
has requested reimbursement for lumbar spine MRI performed on 4/30/21.
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Overturned
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Medical Necessity
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Summary Reviewer
The patient is a 50-year-old male who presented with onset of lumbar radiculopathy. The patient
has requested reimbursement for lumbar spine MRI performed on 4/30/21. The physician
reviewer found that the submitted documentation supports the medical necessity of the services
at issue. According to the literature, symptoms of radiculopathy are most commonly associated
with nerve irritation from a compressive force, such as disc extrusion/herniation, hypertrophic
spine changes, and sometimes even infectious processes. Berry and colleagues noted, The
optimal imaging modality for the evaluation of radiculopathy is MRI of the lumbar spine without
contrast, which can show compression of the nerve root. MRI can guide potential surgical
intervention. Per American College of Radiology Appropriateness Criteria for the evaluation of
progressive symptoms of lumbar spine pain and radiculopathy, MRI of lumbar is usually
appropriate, the highest category for recommendation of imaging. The current medical
evidence supports the services at issue for the evaluation of this patients progressive pain and
radiculopathy. Therefore, lumbar spine MRI performed on 4/30/21 was medically necessary for
the evaluation of this patient.
| 1 |
The parent of a three-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient mental health treatment for children and adolescents provided from 12/31/18 through 6/29/19. 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 medical condition.
The patient has had deterioration in expected level of functioning in relationships with peers, adults and family, and he is struggling with serious daily behavioral issues.
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Overturned
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Medical Necessity
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Summary Reviewer
The parent of a three-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient mental health treatment for children and adolescents provided from 12/31/18 through 6/29/19. 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 medical condition. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 2 due to the patients history of impulsive behaviors. In terms of functional status, the records support a score of 2. The patient has had deterioration in expected level of functioning in relationships with peers, adults and family, and he is struggling with serious daily behavioral issues. In terms of comorbidity, the records support a score of 1. The patient does not have medical problems or substance use. With regards to level of stress of the recovery environment, the records support a score of 3. The patient has problematic issues with family relationships. In terms of level of support of the recovery environment, the records support a score of 2. The patients family actively participates in treatment, although their relationship appears to be strained. With regards to resiliency and treatment history, the records support a score of 3 due to recent minimal progress in the intensive outpatient program. In terms of acceptance and engagement of the child, the records support a score of 3. The patient participates minimally. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 18. The score correlates with intensive outpatient program services. Therefore, intensive outpatient mental health treatment for children and adolescents provided from 12/31/18 through 6/29/19 was and is medically necessary for the treatment of this patient.
| 1 |
A 64-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay testing provided on 9/1/16. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees cutaneous melanoma.
that the records indicate the patient presented to his provider with a recently diagnosed 1.4 mm Breslow depth melanoma on the left flank.
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Upheld
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Medical Necessity
|
Summary Reviewer
A 64-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay testing provided on 9/1/16. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the records indicate the patient presented to his provider with a recently diagnosed 1.4 mm Breslow depth melanoma on the left flank. The National Comprehensive Cancer Network (NCCN) has determined that this type of gene testing for melanoma is not recommended for routine use and should not be used outside of a clinical trial setting. Currently, the DecisionDx melanoma gene test is not considered to be the standard of care. The DecisionDx melanoma gene test is based on studies of ocular melanoma and it has not established that the findings are extended to cutaneous melanoma. For these reasons, the DecisionDx melanoma assay testing provided on 9/1/16 was not medically necessary for evaluation of this patients melanoma. Based on the foregoing discussion, the testing at issue was 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 male with a history of urothelial cancer status post resection. The patient developed gross hematuria and computed tomography (CT) abdomen in August 2015 revealed left hydroureter and mild left hydronephrosis with soft tissue attenuation seen in distal left ureter. The patient underwent FoundationOne testing on 5/4/16. The patient is requesting reimbursement for the FoundationOne gene testing performed on 5/4/16. The Health Insurer has denied this request as investigational.
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Overturned
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Experimental
|
Summary Reviewer 1
The patient is a 63-year-old male with a history of urothelial cancer status post resection. The patient developed gross hematuria and computed tomography (CT) abdomen in August 2015 revealed left hydroureter and mild left hydronephrosis with soft tissue attenuation seen in distal left ureter. The patient underwent FoundationOne testing on 5/4/16. The patient is requesting reimbursement for the FoundationOne gene testing performed on 5/4/16. The Health Insurer has denied this request as investigational. The FoundationOne gene testing performed on 5/4/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines do not include next generation sequencing in the treatment of urothelial cancer. Clinical outcomes in the treatment of metastatic bladder cancer is not based on complete genomic panel testing. Broad genomic panel testing such as FoundationOne is not considered the standard of care in tis clinical setting. The available literature on clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions on clinical utility. In addition, there is potential for harm if ineffective therapy is given based on test results, because there may be adverse effects of therapy in absence of a benefit. All told, the testing at issue 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 |
A 54-year-old female enrollee requested authorization and coverage for arthrodesis sacroiliac joint percutaneous. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees bilateral sacroiliitis.
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Overturned
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Experimental
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Summary Reviewer 3
A 54-year-old female enrollee requested authorization and coverage for arthrodesis sacroiliac joint percutaneous. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees bilateral sacroiliitis. The physician reviewer found There is a growing body of literature looking at sacroiliac fusion and minimally invasive SI fusion in particular. This included randomized controlled trials, a few systematic reviews, and multiple other peer-reviewed studies. However, there continues to be concerns about the quality of the literature available and inherent biases present with many of the studies being industry sponsored and a lack of high level evidence and homogeneity of patient populations and outcome measurements. Furthermore, there are still concerns with symptom overlap from SI joint and other closely related pathology. Based on the patients generalized pain profile as outlined in her subjective pain complaints and pain diagram, as well as the underlying diagnoses of chronic lower back pain and fibromyalgia, there is no clear evidence supporting that the requested services will likely be more beneficial than the available standard therapy for treatment of this patients medical condition. 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 female has requested reimbursement gene testing performed on 11/01/15. 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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Upheld
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Experimental
|
Summary Reviewer 3
A 62-year-old female has requested reimbursement gene testing performed on 11/01/15. 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 the current medical evidence has not demonstrated the superior efficacy of the services at issue in this clinical setting. There is a lack of data supporting an enhanced survival benefit for the use of molecular profiling in the front-line setting for treatment, as few actionable mutations are identified and primary treatment strategies are relatively standard. The role in recurrent/refractory disease is developing and identification of specific targets for either clinical trial selection or selection of chemotherapy agents may be helpful, although this has yet to be proven. Thus, gene testing performed on 11/01/15 was not 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 not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 0 |
A 52-year-old male insured has requested authorization and coverage for Panzyga (immune globulin
(Human)-ifas). The Health Insurer has denied this request indicating that the requested treatment is
considered investigational for the treatment of the insureds small fiber neuropathy and paresthesia of
the feet.
records indicate that this patient has a history of small
fiber neuropathy and CISP.
In this case, the patient has
previously undergone treatment with IVIG with an improvement of symptoms and function. The
discontinuation of IVIG
the patients symptoms. Moreover, the patient has tried
and failed numerous medications, including Effexor, Elavil, Lyrica, Cymbalta, gabapentin, meloxicam,
mexiletine, and topical lidocaine.
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Overturned
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Experimental
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Summary Reviewer 3
A 52-year-old male insured has requested authorization and coverage for Panzyga (immune globulin
(Human)-ifas). The Health Insurer has denied this request indicating that the requested treatment is
considered investigational for the treatment of the insureds small fiber neuropathy and paresthesia of
the feet. The physician reviewer found that the records indicate that this patient has a history of small
fiber neuropathy and CISP. A study by Koh and colleagues reported that early, aggressive immunotherapy with IVIG is an effective treatment option for patients with CISP. Similarly, Shelly and
colleagues found that immunotherapy benefitted 93% of patients with CISP. In this case, the patient has
previously undergone treatment with IVIG with an improvement of symptoms and function. The
discontinuation of IVIG led to a resumption of the patients symptoms. Moreover, the patient has tried
and failed numerous medications, including Effexor, Elavil, Lyrica, Cymbalta, gabapentin, meloxicam,
mexiletine, and topical lidocaine. Overall, the medical literature and the patients past treatment
success with IVIG indicate that IVIG therapy is likely to be efficacious for this patient. All told, the
requested Panzyga (immune globulin (Human)-ifas) is likely to be more beneficial for the treatment of
the patients condition than any available standard therapy.
| 1 |
A 35-year-old male enrollee has requested reimbursement for rhinoplasty, secondary; major revision (nasal tip work and osteotomies) performed on 11/13/15. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees nasal obstruction.
This patient had valve collapse, and vestibular stenosis repair should improve his nasal breathing.
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Upheld
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Medical Necessity
|
Summary Reviewer
A 35-year-old male enrollee has requested reimbursement for rhinoplasty, secondary; major revision (nasal tip work and osteotomies) performed on 11/13/15. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees nasal obstruction. The physician reviewer found that functional rhinoplasty has been demonstrated to improve nasal breathing by addressing structural abnormalities of the nose. However, there was no documentation of preoperative physical examination describing these abnormalities except for the operative note describing valve collapse on the right. Internal valve collapse can lead to nasal obstruction. Placement of precise cartilage grafts have been demonstrated to provide support which improves nasal breathing. This patient had valve collapse, and vestibular stenosis repair should improve his nasal breathing. Therefore, this procedure was medically indicated. However, the osteotomies, cephalic trim and alar reduction were likely cosmetic and not medically necessary. As such, the rhinoplasty was not medically necessary because the osteotomies and tip work were cosmetic in nature. Therefore, the rhinoplasty, secondary; major revision (nasal tip work and osteotomies) performed on 11/13/15 were not medically necessary. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
The patient is a 17-year-old female with a past psychiatric history of major depressive disorder,
recurrent, moderate, attention deficit hyperactivity disorder, and generalized anxiety disorder. The
patients parent has requested reimbursement for residential treatment center services provided
from 9/21/21 through 10/20/21. The Health Insurer has denied this request and reported that the
services at issue were not medically necessary for the treatment of this patient.
|
Upheld
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Medical Necessity
|
Summary Reviewer
The patient is a 17-year-old female with a past psychiatric history of major depressive disorder,
recurrent, moderate, attention deficit hyperactivity disorder, and generalized anxiety disorder. The
patients parent has requested reimbursement for residential treatment center services provided
from 9/21/21 through 10/20/21. The Health Insurer has denied this request and reported that the
services at issue were not medically necessary for the treatment of this patient. This denial is the
subject of this appeal and determination. The physician reviewer found that the American
Academy of Child and Adolescent Psychiatry (AACAP) and American Association for
Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization
System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a
single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System
(CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of
services needed for children and adolescents, 6-18 years of age, presenting with psychiatric,
substance use, medical and/or developmental concerns. Using CALOCUS-CASII, providers score
patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions
include: (1) risk of harm; (2) functional status; (3) co-occurrence of developmental, medical,
substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports);
(5) resiliency and response to services; and (6) engagement. The composite score is then used to
determine the level of care needed. Applying the CALOCUS-CASII framework, the patient did
not meet the criteria for residential treatment center services provided from 9/21/21 through
10/20/21. For dimension 1, risk of harm, the records support a score of 3. This dimension assesses
potential for harm to self or others, or having harm inflicted upon them. The patient has had
intermittent suicidal thoughts over the past year. She has never attempted suicide. She has self-
harmed twice in the previous year and engaged in minor self-harm during her stay in residential
treatment center. The patient denied active suicidal ideation throughout her stay in the residential
treatment center, although she did endorse passive suicidal ideation shortly before discharge. For
dimension 2, functional status, the records support a score of 3. This dimension assesses the degree
to which a person is able to fulfill responsibilities within developmental constraints. The patient
struggled to do things secondary to her anxiety. She was not waking up until noon and wore the
same clothes for several days in a row. She was verbally aggressive towards her parents. For
dimension 3, co-occurring developmental, medical, substance use and psychiatric conditions, the
records support a score of 3. This dimension assesses the co-existence of disorders across four
domains (psychiatric, substance use, medical or developmental) that may complicate the course of
treatment. The patient has mild co-occurrence as evidenced by a neurodevelopmental disorder
(attention deficit/hyperactivity disorder) in addition to her psychiatric disorders of depression and
anxiety. The patient also struggles with insomnia, which may be secondary to anxiety and
depression but can also exacerbate these conditions. For dimension 4A, level of stress in the
recovery environment, the records support a score of 3. This dimension assesses the stressors in
the environment, social circumstances, and interpersonal relationships. The patient has a history
of being bullied. She struggles academically. Her mother had cancer two years ago, and the patient
is concerned about the cancer returning. For dimension 4B, level of support of the recovery
environment, the records support a score of 3. This dimension assesses the presence of family and
social support to augment the recovery environment. Her parents appear supportive of the patient.
For dimension 5, resiliency and response to services, the records support a score of 2. This
dimension assesses how past experiences with treatment and recovery might indicate how the
patient might respond in the future. Prior treatment has included several years of outpatient psychiatric treatment, including multiple psychotropic medication trials. For dimension 6,
engagement of the patient, the records support a score of 3. The child and adolescent sub-
dimension assesses the patients ability to form therapeutic relationship within developmental
constraints. This patient was adequately engaged throughout treatment but struggled to utilize
coping skills at times as evidenced by her engagement in self-harm while in the residential
treatment center. These findings give the patient a composite score of 20, which is consistent with
Level 4 Medically Monitored Community Based Services. Therefore, residential treatment center
services provided from 9/21/21 through 10/20/21 were not medically necessary for the treatment
of this patient.
| 1 |
A 30-year-old female enrollee has requested reimbursement for genetic testing on 4/14/22. The
Health Insurer has denied this request and reported that the service at issue was investigational for
the evaluation of cystic fibrosis of the enrollees fetus.
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Overturned
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Experimental
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Summary Reviewer 2
A 30-year-old female enrollee has requested reimbursement for genetic testing on 4/14/22. The
Health Insurer has denied this request and reported that the service at issue was investigational for
the evaluation of cystic fibrosis of the enrollees fetus. The physician reviewer found that Hurt and
colleagues report that isolated echogenic bowel was associated with an increased risk of congenital
anomalies. Echogenic bowel is diagnosed in 0.2% to 1.4% of second trimester ultrasonographic
examinations and occurs as a normal variant in the second trimester but has also been associated
with several pathologic conditions that include cystic fibrosis, chromosomal abnormalities, and in
utero infection with cytomegalovirus and toxoplasmosis. The diagnosis of fetal echogenic bowel
in the second trimester has significant implications for prenatal management. The SMFM notes,
For fetuses with isolated echogenic bowel, we recommend an evaluation for cystic fibrosis and
fetal cytomegalovirus infection and a third-trimester ultrasound examination for reassessment and
evaluation of growth. The risk for cystic fibrosis ranges from zero to 13% in the presence of
isolated echogenic bowel. The finding of dilated loops of bowel in addition to echogenic bowel
may increase this risk to as high as 17%. Parental cystic fibrosis carrier status should be determined
if not previously assessed in the current or a previous pregnancy. If both parents are carriers,
genetic counseling should be undertaken to discuss the risks and benefits of invasive testing for
fetal genotyping. Racial and ethnic limitations of current cystic fibrosis screening panels should
be considered when interpreting test results. While the American College of Medical Genetics
(ACMG) recommends testing for the 23 most common mutations, current medical literature notes
that there is a lack of coverage for diverse populations by the 23 variants recommended by the
ACMG. Beauchamp and colleagues report, Modern next generation sequencing (NGS) and
variant interpretation enable accurate sequencing-based cystic fibrosis screening. Limiting screening to 23 variants does not improve analytical validity, clinical validity, or clinical utility,
but does fail to detect approximately 30% of at-risk couples. In this clinical setting, the service at
issue was likely to have been more beneficial than the standard screening of 23 variants
recommended by the ACMG, which may result in missed cases of cystic fibrosis. Therefore,
genetic testing on 4/14/22 was likely to have been more beneficial for evaluation of the patients
condition than any available standard therapy.
| 0 |
A 26-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition.
|
Upheld
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Experimental
|
Summary Reviewer 2
A 26-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that various (mostly retrospective) studies of prognostic gene expression profiling (GEP) testing suggest its role as an independent predictor of worse outcome, although not superior to Breslow thickness or sentinel lymph node status. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models. Therefore, DecisionDx-Melanoma testing performed on 4/15/19 was not likely to have been more beneficial than other available standard therapy.
| 0 |
A 50-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.
|
Upheld
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Experimental
|
Summary Reviewer 3
A 50-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with a high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 8/03/18 was not likely to have been more beneficial than other methods of evaluating this patient.
| 0 |
A 51-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) performed on 3/18/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.
|
Overturned
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Experimental
|
Summary Reviewer 3
A 51-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) performed on 3/18/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that patients with vaginitis can be evaluated and treated with an examination, microscopy and/or cultures, depending on the patients symptoms and findings. This patient reported itching and discharge. The services performed in this patients case were clinically appropriate. Per the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin number 215, Although microscopy with Amsel criteria and Gram staining with Nugent scoring remain the preferred methods and the most cost-effective way to diagnosis bacterial vaginosis, some newer commercially available diagnostic tests show promise for use in the clinical setting and may be considered when microscopy is unavailable. Per the medical evidence, this single-swab multiplex test may be a promising alternative to microscopy. Thus, PCR testing performed on 3/18/19 was likely to have been more beneficial than other methods of evaluating this patient.
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A 21-year-old female enrollee has requested authorization and coverage for placement of a cardiovascular defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee who has a family history of early repolarization syndrome (ERS) and an episode of syncope.
The patient is a 21-year-old female with a family history of early repolarization syndrome (ERS) confirmed by genetic testing demonstrating mutations in the gene encoding for the ATP-sensitive potassium (+) channel. Her parents are heterozygous for genetic variants associated with the condition. The patient has a brother who had an aborted sudden cardiac arrest during exercise and who is homozygous for both variants. The patient has another brother who had syncope and who is heterozygous for both variants. The brothers have defibrillators in place. The patient was determined to be homozygous for the same two variants. In addition the patient has had two episodes of documented unexplained syncope. The treating provider recommended placement of cardiovascular defibrillator. The Health Insurer denied coverage for the implantable defibrillator as
the patient has a strong family history of ERS with clinic events
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Overturned
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Experimental
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Summary Reviewer 1
A 21-year-old female enrollee has requested authorization and coverage for placement of a cardiovascular defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee who has a family history of early repolarization syndrome (ERS) and an episode of syncope. The physician reviewer found The patient is a 21-year-old female with a family history of early repolarization syndrome (ERS) confirmed by genetic testing demonstrating mutations in the gene encoding for the ATP-sensitive potassium (+) channel. Her parents are heterozygous for genetic variants associated with the condition. The patient has a brother who had an aborted sudden cardiac arrest during exercise and who is homozygous for both variants. The patient has another brother who had syncope and who is heterozygous for both variants. The brothers have defibrillators in place. The patient was determined to be homozygous for the same two variants. In addition the patient has had two episodes of documented unexplained syncope. The treating provider recommended placement of cardiovascular defibrillator. The Health Insurer denied coverage for the implantable defibrillator as investigational for treatment of this patient. The medical literature supports the requested device for patients who have a genetic predisposition to sudden cardiac death, as evidenced by clinical events in first degree relatives and confirmation of shared genetic variants associated with the condition. (Priori, et al). ERS is associated with an increased risk of idiopathic ventricular fibrillation and sudden death (Adler, et al). Based on the records provided, the patient has a strong family history of ERS with clinic events as well identified shared gene defects associated with the condition. The patient also reported a personal history of unexplained syncope. In this circumstance of a strong family history of aborted sudden cardiac arrest in first degree family members, symptoms of syncope, and confirmation of shared homozygous genetic variants associated with the condition, placement of a defibrillator is highly effective and considered standard accepted practice in the medical community. Moreover, the patients personal history of syncope strengthens the likely benefit for defibrillator placement. As such, the placement of cardiovascular defibrillator is likely to be superior to other forms of therapy available for the treatment of this patient. Therefore, for the reasons stated above, the cardiovascular defibrillator 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.
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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 3
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 there is a lack of support for the services at issue in this clinical setting. The only clinical information available for review are the requisition and report of test results. Per the medical evidence, management includes surveillance testing. However, there was insufficient information submitted to determine if there were other features of the patients clinical situation that would make him moderate or high risk. Therefore, there is insufficient information to determine whether the services at issue were likely to be more beneficial than any available standard therapy. Thus, gene testing performed on 9/11/17 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.
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A 60-year-old male enrollee has requested reimbursement for Oncotype testing performed on 4/25/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.
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Overturned
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Experimental
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Summary Reviewer 2
A 60-year-old male enrollee has requested reimbursement for Oncotype testing performed on 4/25/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that National Comprehensive Cancer Network guidelines indicate that men with low or favorable intermediate risk disease post biopsy may consider the use of tumor-based molecular assays, such as Oncotype DX testing. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. In sum, Oncotype DX testing performed on 4/25/19 was likely to have been more beneficial than other methods of evaluating this patient.
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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 patient has left upper extremity symptoms and subtle findings of a cervical radiculopathy (Polston) with mild left triceps weakness and
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Upheld
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Experimental
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Summary Reviewer 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. The physician reviewer found that the requested services are not likely to be more effective for this patient than other available options. Based on the documentation submitted for review, the patient has left upper extremity symptoms and subtle findings of a cervical radiculopathy (Polston) with mild left triceps weakness and no atrophy/loss of sensation, nor reflex changes. In addition, two level artificial disc replacement remains controversial. The study by Davis and colleagues is a promising study but lacks long term safety and effectiveness data to make conclusions. There is a lack of randomized, prospective, scientific studies that have shown the long term safety and effectiveness of the proposed procedure. All told, the requested neck surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
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A 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain.
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Overturned
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Experimental
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Summary Reviewer 2
A 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain. The physician reviewer found the medical literature recommends using a pain diary to verify when the local anesthetic wore off for the treatment of diagnostic medial branch block prior to radiofrequency ablation (Derby, et al). According to the documentation available for review, the records do not document a pain diary. Moreover, it is unclear that she obtained significant benefit from the prior radiofrequency ablation. The record submitted does not support that she did obtain relief to corroborate improvement, with no mention of increased functional benefit from a baseline or decrease in perceived pain from a baseline. Therefore, the request for radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 33-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 6/11/17 through 7/2/17. 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 patients debilitating formal thought disorder fueled impairment in all functional domains. He was treated with a relatively high dose of clozapine, which is a
. In addition to his psychosis, the patient had co-occurring depression, anxiety, addictive illness and thyroid disease and history of multiple psychiatric hospitalizations including prior admissions during the episode of illness. On 6/11/17, the patient was mildly anxious and labile. His insight and judgment were both impaired. He reported suicidal ideation and auditory hallucinations. He had recently relapsed on methamphetamine. Given these reports, the patient had not yet consolidated the treatment gains necessary to succeed in the outpatient setting. However, the patient remained engaged in active treatment. He was described by staff as depressed, lethargic, flat, constricted and distracted. He had frequent auditory hallucinations. He had thought blocking on 6/29/17. Further, he was experiencing sedation with the increasing doses of clozapine and amitriptyline.
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Overturned
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Medical Necessity
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Summary Reviewer
A 33-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 6/11/17 through 7/2/17. 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 based on the available documentation, the services provided from 6/11/17 through 7/2/17 were medically necessary for treatment of this patients schizoaffective disorder and stimulant use disorder. The RTC services could not have been adequately and effectively delivered in a less restrictive setting. The patients debilitating formal thought disorder fueled impairment in all functional domains. He was treated with a relatively high dose of clozapine, which is a complex antipsychotic typically reserved for the most refractory of cases. In addition to his psychosis, the patient had co-occurring depression, anxiety, addictive illness and thyroid disease and history of multiple psychiatric hospitalizations including prior admissions during the episode of illness. On 6/11/17, the patient was mildly anxious and labile. His insight and judgment were both impaired. He reported suicidal ideation and auditory hallucinations. He had recently relapsed on methamphetamine. Given these reports, the patient had not yet consolidated the treatment gains necessary to succeed in the outpatient setting. However, the patient remained engaged in active treatment. He was described by staff as depressed, lethargic, flat, constricted and distracted. He had frequent auditory hallucinations. He had thought blocking on 6/29/17. Further, he was experiencing sedation with the increasing doses of clozapine and amitriptyline. During the disputed timeframe, the residential setting was reasonably expected to improve the patients condition and prevent a more serious episode of illness. The duration of services was consistent with community standards for a case of this complexity. Considering the chronicity and severity of the disease burden, the RTC services provided from 6/11/17 through 7/2/17 were medically necessary for treatment of this patients medical condition. 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.
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A 57-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission. The Health Insurer has denied this request indicating that requested services are considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes.
this patient is an adult with morbid obesity and a BMI of 48.9 kg/m2.
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Overturned
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Experimental
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Summary Reviewer 1
A 57-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission. The Health Insurer has denied this request indicating that requested services are considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes. The physician reviewer found that this patient is an adult with morbid obesity and a BMI of 48.9 kg/m2. The medical literature indicates that the duodenal switch (DS) is associated with significantly more risk of micronutrient and protein malnutrition. In this patients case, there are no recent dietary or psychological evaluations provided for review. Separately, there is additional risk involved and a separate psychological evaluation needs to be performed to ensure that this patient has the appropriate current level of understanding and an appropriate candidate for reoperative bariatric surgery. There is no complication of the prior sleeve gastrectomy that requires surgical treatment. There is also no record of a comprehensive updated multidisciplinary evaluation. Additionally, the record does not indicate that the additional micronutrient risks have adequately been addressed at this time. As such, biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission are not likely to be superior over the standard methods for the treatment of this patient.Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 42-year-old female enrollee has requested authorization and coverage for substance use inpatient detoxification provided from 10/03/18 through 10/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions.
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Upheld
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Medical Necessity
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Summary Reviewer
A 42-year-old female enrollee has requested authorization and coverage for substance use inpatient detoxification provided from 10/03/18 through 10/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Society of Addiction Medicine (ASAM) criteria for level of placement can be applied to the patients presentation to help determine the appropriate level of care. The patient did not meet the criteria for dimension 1) acute intoxication and/or withdrawal potential. Additionally, the patient did not meet the criteria for dimension 2) biomedical condition and complications. According to the ASAM criteria, all six dimensions must be met for placement in this level of care. Therefore, substance use inpatient detoxification from 10/03/18 through 10/08/18 were not medically necessary for the treatment of this patient.
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The patient is a 41-year-old female with an onset of right knee pain on 7/04/16 due to a fall. On 7/06/16, right knee x-ray documented minimal degenerative changes. Findings documented the joint spaces were well-maintained, with sharpening of the posterior superior patellar margin suggesting early degenerative change. On 7/20/16, right knee magnetic resonance imaging (MRI) documented chondromalacia patella with mild diffuse articular cartilage loss of the patellar apex, medial patella facet, and medial trochlea. There was focal inflammation of the suprapatellar fat. On 12/19/16, the records noted persistent anterior knee pain with associated swelling. Conservative treatment had included physical therapy and corticosteroid injection with temporary relief. Right knee examination documented retropatellar tenderness, range of motion 0 to 120 degrees with patellofemoral crepitation, no instability, and negative meniscal signs. Review of the prior MRI revealed chondromalacia patella with a mild diffuse cartilage loss and focal inflammation in the suprapatellar fat pad. The diagnosis was chondromalacia patella, right knee, and rule-out inflammatory arthritis. She had significant anterior knee pain likely related to chondromalacia. There was evidence of synovial inflammation, and rheumatology consultation was recommended for further evaluation. On 1/30/17, second opinion orthopedic report cited persistent right knee pain. The diagnosis was right knee patellofemoral chondromalacia status post fall. She had previously undergone treatment, including medical management, physical therapy, and corticosteroid injection. She had not experienced lasting improvement with treatment
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Upheld
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Medical Necessity
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Summary Reviewer
The patient is a 41-year-old female with an onset of right knee pain on 7/04/16 due to a fall. On 7/06/16, right knee x-ray documented minimal degenerative changes. Findings documented the joint spaces were well-maintained, with sharpening of the posterior superior patellar margin suggesting early degenerative change. On 7/20/16, right knee magnetic resonance imaging (MRI) documented chondromalacia patella with mild diffuse articular cartilage loss of the patellar apex, medial patella facet, and medial trochlea. There was focal inflammation of the suprapatellar fat. On 12/19/16, the records noted persistent anterior knee pain with associated swelling. Conservative treatment had included physical therapy and corticosteroid injection with temporary relief. Right knee examination documented retropatellar tenderness, range of motion 0 to 120 degrees with patellofemoral crepitation, no instability, and negative meniscal signs. Review of the prior MRI revealed chondromalacia patella with a mild diffuse cartilage loss and focal inflammation in the suprapatellar fat pad. The diagnosis was chondromalacia patella, right knee, and rule-out inflammatory arthritis. She had significant anterior knee pain likely related to chondromalacia. There was evidence of synovial inflammation, and rheumatology consultation was recommended for further evaluation. On 1/30/17, second opinion orthopedic report cited persistent right knee pain. The diagnosis was right knee patellofemoral chondromalacia status post fall. She had previously undergone treatment, including medical management, physical therapy, and corticosteroid injection. She had not experienced lasting improvement with treatment to date. The treatment plan recommended a viscosupplementation injection series. The patient has requested coverage for Supartz FX 25 mg/2.5 ml syringe 10 mg. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The submitted documentation fails to demonstrate the medical necessity of the requested services. Evidence-based medical guidelines state that hyaluronic acid injections in the knee, such as Supartz, are recommended as a possible option for severe osteoarthritis for patients who have not responded adequately to recommended conservative treatments, to potentially delay total knee replacement. There is insufficient evidence for other conditions, including patellofemoral arthritis, chondromalacia patella, patella-femoral syndrome (kneecap pain), or osteochondritis dissecans. This patient presents with persistent right anterior knee pain with swelling. Functional difficulty was reported in activities of daily living and work activities. Clinical examination findings were consistent with imaging evidence of right knee chondromalacia patella. Conservative treatment has included medications, activity modification, physical therapy, and corticosteroid injection, without sustained improvement. The current medical guidelines and peer-reviewed literature does not support the use of Supartz injections for a diagnosis of chondromalacia patella or patellofemoral arthritis since the effectiveness of hyaluronic acid injections for these indications has not been established. Therefore, the requested Supartz FX 25 mg/2.5 ml syringe 10 mg is not medically indicated for the treatment of this patient. Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
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A 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain.
In this case the patient meets North American Spine Society criteria for the proposed sacroiliac joint fusion. She has had at least 75 percent reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular SIJ injection on two separate occasions. In addition, the postoperative CT scan on 11/5/15 shows no ongoing neural compression and no central canal or foraminal stenosis on the postoperative CT scan.
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Overturned
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Experimental
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Summary Reviewer 2
A 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain. The physician reviewer found that the North American Spine Societys recommendations include that percutaneous sacroiliac joint fusion should only be considered when all inclusion criteria have been met. The authors state that due to the relatively moderate evidence, it is particularly critical that inclusion criteria are scrutinized and patient selection is executed with vigilance. In this case the patient meets North American Spine Society criteria for the proposed sacroiliac joint fusion. She has had at least 75 percent reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular SIJ injection on two separate occasions. In addition, the postoperative CT scan on 11/5/15 shows no ongoing neural compression and no central canal or foraminal stenosis on the postoperative CT scan. This patient meets all NASS criteria for the proposed surgery. For these reasons, sacroiliac joint fusion surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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A 45-year-old female enrollee has requested authorization and coverage for transforaminal epidural injection of the lumbar or sacral (CPT codes 64483 and 64484). The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees chronic low back pain.
. In addition, the provider has documented appropriate patient response to the previous injections with more than 80% pain relief of symptoms and leg pain lasting for over 10 months. After the
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Overturned
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Medical Necessity
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Summary Reviewer
A 45-year-old female enrollee has requested authorization and coverage for transforaminal epidural injection of the lumbar or sacral (CPT codes 64483 and 64484). The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees chronic low back pain. The physician reviewer found that based on the presented clinical records submitted for review, transforaminal epidural injection of the lumbar or sacral (CPT codes 64483 and 64484) is medically necessary for treatment of the patients medical condition. There is sufficient peer-reviewed literature supporting the requested service in this clinical setting. Manchikanti and colleagues show good evidence with the use of transforaminal epidural injections in managing disc herniation and radiculitis. According to the documentation submitted for review, a repeat transforaminal epidural steroid injection of the lumbar spine is clinically indicated due to the patients return of pain which was identical to the pain prior to the previous injection. In addition, the provider has documented appropriate patient response to the previous injections with more than 80% pain relief of symptoms and leg pain lasting for over 10 months. After the previous injections the patient did not require pain medications and has had adequate conservative treatment including physical therapy. For the reasons provided, the requested service has been established as medically necessary for treatment of the patients medical condition. Therefore, the requested service is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
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A 57-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 6/24/16. The Health Plan has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees breast examination.
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Upheld
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Medical Necessity
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Summary Reviewer
A 57-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 6/24/16. The Health Plan has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees breast examination. The physician reviewer found that the tomosynthesis often allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging alone. The American College of Radiology (ACR) considers 2D mammography as medically necessary for the screening of breast cancer, and considers the addition of tomosynthesis to be of added value for patients with dense breast tissue. Although breast tomosynthesis has become widely accepted in the breast imaging arena, breast tomosynthesis performed on 6/24/16 is not considered medically necessary for evaluation of the patients medical condition. Therefore, the service at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
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The parent of a 17-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 11/16/15 through 12/15/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse, depression, and post-traumatic stress disorder (PTSD). The physician
the records indicate that this patient had been receiving treatment at the IOP level of care for the three months immediately prior to his admission to RTC. He was transferred because he was not making progress and was considered at high risk for suicide. His history also reveals severe functional impairment. In addition, he had three previous psychiatric hospital admissions prior to the RTC.
IOP, and had a history that his providers noted placed him at high risk for destabilization and relapse
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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 residential treatment center (RTC) services provided from 11/16/15 through 12/15/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse, depression, and post-traumatic stress disorder (PTSD). The physician reviewer found that the records indicate that this patient had been receiving treatment at the IOP level of care for the three months immediately prior to his admission to RTC. He was transferred because he was not making progress and was considered at high risk for suicide. His history also reveals severe functional impairment. In addition, he had three previous psychiatric hospital admissions prior to the RTC. Thus, he meets the American Society of Addiction Medicine (ASAM) criteria for 24-hour treatment as he was considered a high risk for harm, he had severe social impairment that could not be managed with IOP, and had a history that his providers noted placed him at high risk for destabilization and relapse without RTC level of care. He also needed high levels of motivation from staff to address his lack of treatment engagement. Given these findings, the RTC services provided from 11/16/15 through 12/15/15 were medically necessary for treatment of this patients medical condition. 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.
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A 58-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/10/15. 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 3
A 58-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/10/15. 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 breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. However, in this patients case, there were no problems to be resolved. The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications. In addition, there had been no change when compared to yearly mammograms dating back eight years. Thus, breast tomosynthesis performed on 7/10/15 was not likely to have been of greater benefit than other modalities. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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The patient is a 56-year-old female with a history of relapsing multiple sclerosis, type 1 diabetes, and hypothyroidism. The patient has requested authorization and coverage for Acthar (corticotropin injection gel 80 units/mL). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient.
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Overturned
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Medical Necessity
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Summary Reviewer
The patient is a 56-year-old female with a history of relapsing multiple sclerosis, type 1 diabetes, and hypothyroidism. The patient has requested authorization and coverage for Acthar (corticotropin injection gel 80 units/mL). 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 standard therapy for acute exacerbations of multiple sclerosis has been high-dose corticosteroid therapy. Adrenocorticotropic hormone (H.P. Acthar gel) has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of exacerbations of multiple sclerosis in adults. Other therapies include plasmapheresis and intravenous immunoglobulin (IVIG). Plasmapheresis is generally reserved for treatment of relapses that are severe or refractory to treatment with high-dose corticosteroids. IVIG is sometimes used in patients for whom high-dose corticosteroids are contraindicated or not tolerated, but there is a lack of consistent evidence for its use in relapse management. Per Ross and colleagues, adrenocorticotropic hormone gel may be considered as an alternative treatment of multiple sclerosis relapses and is generally used as an alternative to high-dose corticosteroids. The authors noted, that the reasons for using adrenocorticotropic hormone include a lack of benefit established with corticosteroids, inability to tolerate corticosteroids or adverse effects, and poor intravenous access. Its efficacy has been studied in several published investigations, and treatment outcomes may be comparable to those seen with corticosteroids. Bell and colleagues performed a randomized, open-label, crossover study that evaluated 18 patients with multiple sclerosis treated with subcutaneous H.P. Acthar gel and intravenous methylprednisolone. Preliminary results suggest that fewer drug-related adverse effects occurred with Acthar gel than intravenous methylprednisolone for treatment of multiple sclerosis exacerbations. Kutz performed a retrospective review of patients with multiple sclerosis exacerbations and diabetes treated with Acthar gel. The data suggested that Acthar gel may be a well-tolerated and effective treatment option for patients with diabetes experiencing a multiple sclerosis relapse. In this case, the patient has multiple sclerosis with uncontrolled exacerbations and has failed conventional therapy with high-dose corticosteroid therapy. She also has diabetes and developed uncontrolled blood sugars with corticosteroid treatment. She seeks approval for Acthar gel for treatment of acute exacerbations. Acthar gel is an FDA approved therapy for multiple sclerosis exacerbations and is used for patients who fail corticosteroids and patient who are unable to tolerate corticosteroids or their side effects, both of which apply in this case. Therefore, Acthar (corticotropin injection gel 80 units/mL) is medically necessary for the treatment of this patient.
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The patient is a 43-year-old female who has a history of right sided low back. She reported increasing low back pain over the past several years. The patient has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patients low back pain.
A magnetic resonance imaging was noted as showing degenerative disc disease but no lesions were found.
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Overturned
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Experimental
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Summary Reviewer 1
The patient is a 43-year-old female who has a history of right sided low back. She reported increasing low back pain over the past several years. The patient has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patients low back pain. There is a lack of long term studies that demonstrate the superior efficacy of the requested procedure in this clinical setting. The effectiveness of sacroiliac joint fusion when compared to standard treatment protocols remains unconvincing as a treatment modality for patients who are diagnosed with low back pain. In this patients case, the documentation does not support evidence of sacroiliac joint instability, fracture, or lesion. A magnetic resonance imaging was noted as showing degenerative disc disease but no lesions were found. The diagnostic imaging does not confirm a medical condition that would provide an indication for sacroiliac joint fusion. Thus, the medical evidence does not support the efficacy of the requested procedure in this patients case. As such, sacroiliac joint fusion is not likely to be of greater benefit for treating this patients medical condition than the available standard treatment methods. Therefore, based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 60-year-old female enrollee has requested reimbursement for Prolia (denosumab) injection administered on 10/20/15. The Health Insurer has denied this request indicating that the medication at issue is considered investigational for treatment of the enrollees osteoporosis.
lia has received Food and Drug Administration approval for the treatment of osteoporosis. The patient has documented osteoporosis with a history of fracture. The DEXA scan of the patients hip and spine demonstrate treatment with Prolia.
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Overturned
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Experimental
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Summary Reviewer 2
A 60-year-old female enrollee has requested reimbursement for Prolia (denosumab) injection administered on 10/20/15. The Health Insurer has denied this request indicating that the medication at issue is considered investigational for treatment of the enrollees osteoporosis. The physician reviewer found upon review of the medical record, Prolia was likely to be more efficacious in treating the patients medical condition than any available standard therapy. A substantial amount of medical evidence exists to support Prolia as an appropriate treatment option for patients with osteoporosis. Furthermore, Prolia has received Food and Drug Administration approval for the treatment of osteoporosis. The patient has documented osteoporosis with a history of fracture. The DEXA scan of the patients hip and spine demonstrate treatment with Prolia. In sum, the second injection of Prolia in October 2015 was beneficial for treatment of this patients osteoporosis.Based upon the information set forth above, the medication at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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A 63-year-old female enrollee has requested reimbursement for advanced lipoprotein testing performed on 10/19/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition.
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Upheld
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Experimental
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Summary Reviewer 3
A 63-year-old female enrollee has requested reimbursement for advanced lipoprotein testing performed on 10/19/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that there is support for a portion of the services at issue. The National Lipid Association stated that lipoprotein (a) testing is reasonable to refine atherosclerotic cardiovascular disease risk in adults with the following: first-degree relatives with premature atherosclerotic cardiovascular disease risk (less than 55 years of age in men; less than 65 years of age in women); a personal history of premature atherosclerotic cardiovascular disease; primary severe hypercholesterolemia (LDL greater than or equal to 190 mg/dL) or suspected familial hypercholesterolemia. This patient does appear to meet the first of these criteria for lipoprotein (a) measurement. Thus, CPT 83695 was likely to have been more beneficial than other available standard methods of evaluating this patient. Apolipoprotein B may be a useful risk assessment tool in patients with normal LDL who have a high family risk for premature coronary artery disease. However, apolipoprotein B assays have not been fully standardized, and there is a lack of consensus on predictive or treatment value. Rosenson suggests the measurement of LDL particle concentration, or the surrogate measure of apolipoprotein B, in individuals with insulin resistance disorders who have not achieved their minimal acceptable LDL cholesterol targets. This patient does not meet these criteria for lipoprotein B measurement. Therefore, CPT codes 82172 and 83704 were not likely to have been more beneficial than other available standard methods of evaluating this patient.
| 0 |
A 59-year-old female enrollee has requested reimbursement for a cooling or combined cooling/heating device. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees medical condition.
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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 a cooling or combined cooling/heating device. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees medical condition. The physician reviewer found the medical evidence has not established the superior efficacy of the device at issue. The use of icepacks has been in regular and common use for decades. In this patients case, there is a lack of evidence indicating that the device at issue was likely to have been more effective than simpler methods of applying cold, such as icepacks. Per the medical literature, simpler applications of cold have been demonstrated to be equally efficacious. Therefore, the device at issue was not likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 0 |
A 55-year-old female enrollee has requested authorization and coverage for botulinum toxin type A (Botox) treatment and ongoing treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.
, the patient failed multiple first-line therapies and had a documented response to Botox. While not
she experienced a significant worsening of her headache frequency.
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Overturned
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Experimental
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Summary Reviewer 3
A 55-year-old female enrollee has requested authorization and coverage for botulinum toxin type A (Botox) treatment and ongoing treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that although Botox is not indicated for every patient with a migraine disorder, it can provide relief in a subset of patients and is U.S. Food and Drug Administration (FDA) approved for this indication. In this particular case, the patient failed multiple first-line therapies and had a documented response to Botox. While not treated with Botox she experienced a significant worsening of her headache frequency. For these reasons, the requested ongoing treatment with Botox is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| 1 |
A 67-year-old female enrollee has requested authorization and coverage for Actemra injections 80 mg/4 mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees rheumatoid arthritis.
in this case, the patient has active, moderate to severe rheumatoid arthritis. She is being treated with prednisone with a history of ongoing osteoporosis. She experienced side effects from the prednisone with multiple fractures. She has failed two different TNFi medications including Enbrel which was ineffective and Humira which caused an adverse reaction. She is noted to have been tuberculosis negative prior to previous TNFi and most recent chest x-ray on 5/11/17 was also negative for tuberculosis. She has failed two TNFi and the guidelines suggest a decreased response to a third TNFi after poor response or inability to use a second TNFi.
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Overturned
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Medical Necessity
|
Summary Reviewer
A 67-year-old female enrollee has requested authorization and coverage for Actemra injections 80 mg/4 mL. 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 in this case, the patient has active, moderate to severe rheumatoid arthritis. She is being treated with prednisone with a history of ongoing osteoporosis. She experienced side effects from the prednisone with multiple fractures. She has failed two different TNFi medications including Enbrel which was ineffective and Humira which caused an adverse reaction. She is noted to have been tuberculosis negative prior to previous TNFi and most recent chest x-ray on 5/11/17 was also negative for tuberculosis. She has failed two TNFi and the guidelines suggest a decreased response to a third TNFi after poor response or inability to use a second TNFi. As such, the request for Actemra injections 80 mg/4 mL is supported as medically necessary for treatment of this patients rheumatoid arthritis. Based on the foregoing, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| 1 |
An 18-year-old male enrollee has requested reimbursement for mental health residential treatment center (RTC) services provided from 7/6/15 through 6/28/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees major depressive disorder and anxiety disorder.
Overall, the patient did not require 24-hour a day seven days per week supervision. The patient did not appear to be at imminent risk of harm to self or others.
On 7/10/15, the patients individual therapy note reported the patients mood was normal and his affect was blunted. On 7/28/15, he had a significant reduction in crying spells since admission to the program. On 8/10/15, he continued to report irritability.
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Upheld
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Medical Necessity
|
Summary Reviewer
An 18-year-old male enrollee has requested reimbursement for mental health residential treatment center (RTC) services provided from 7/6/15 through 6/28/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees major depressive disorder and anxiety disorder. The physician reviewer found that the records provided for review do not meet the medical necessity criteria for the mental health RTC level of care services provided from 7/6/15 through 6/28/16. Overall, the patient did not require 24-hour a day seven days per week supervision. The patient did not appear to be at imminent risk of harm to self or others. Psychiatric issues prompting his admission including depression and irritability could have been safely and efficiently been treated at a less intensive treatment setting. There also was no evidence of any acute impairment, behavior, or issues with cognition that interfered with activities of daily living. Psychosocial and environmental problems were not likely to threaten the patients safety and would not likely have undermined engagement at a less intensive level of care, such as outpatient care. On 7/10/15, the patients individual therapy note reported the patients mood was normal and his affect was blunted. On 7/28/15, he had a significant reduction in crying spells since admission to the program. On 8/10/15, he continued to report irritability. Such treatment issues are those routinely treated in an outpatient clinic and did not require RTC services to be managed effectively. Further, medication changes made during this time did not require RTC level of care and supervision. Depakote was reduced and Seroquel was increased due to low neutrophils. It was also noted he repeatedly was not using his continuous positive airway pressure (CPAP) routinely including on a progress note dated 11/18/15. However, the medication management could have been adequately addressed on an outpatient basis and the use of CPAP could have been supervised by his caregiver at home. On 12/30/15, it was noted that his home visit did not go well. It was reported he had low frustration tolerance and poor mood regulation. However, these issues did not warrant ongoing residential treatment. Moreover, on 5/29/16 it was noted that the patient had no suicidal or homicidal ideations, had no mania, no psychosis, and no agitation. All told, the mental health RTC services provided from 7/6/15 through 6/28/16 were not medically necessary for treatment of this patients behavioral health issues. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
A 40-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/9/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer.
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Overturned
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Experimental
|
Summary Reviewer 2
A 40-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/9/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, the presence of breast implants and the family history of breast cancer are not automatic indications for tomosynthesis. However, the patients breasts are extremely dense, and patients with dense breasts can benefit most from tomosynthesis. The ability to separate overlapping breast tissues and better demonstrate an occult tumor is one of the primary benefits of tomosynthesis. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 9/9/16 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 service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| 1 |
A 40-year-old female enrollee has requested reimbursement for testing for inherited thrombophilic disorders performed on 10/19/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition.
that this patient had two prior early miscarriages. As a result, her provider ordered multiple genetic blood tests for inherited thrombophilias.
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Upheld
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Experimental
|
Summary Reviewer 2
A 40-year-old female enrollee has requested reimbursement for testing for inherited thrombophilic disorders performed on 10/19/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient had two prior early miscarriages. As a result, her provider ordered multiple genetic blood tests for inherited thrombophilias. The use of these tests to evaluate women with prior miscarriages is not supported by available literature. An extensive literature review has shown a lack of association of heterozygosity of the MTHFR mutation and miscarriage. Rey and colleagues concluded, aMethylenetetrahydrofolate mutation, protein C, and antithrombin deficiencies were not significantly associated with fetal loss.a The American College of Obstetricians and Gynecologists does not recommend screening for this in non-pregnant or pregnant women. Thus, testing for inherited thrombophilic disorders performed on 10/19/19 was not likely to have been more beneficial than other available methods of evaluating this patient.
| 1 |
A 29-year-old female enrollee has requested reimbursement for the human papilloma virus (HPV) testing provided on 8/26/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for HPV.
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Upheld
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Experimental
|
Summary Reviewer 3
A 29-year-old female enrollee has requested reimbursement for the human papilloma virus (HPV) testing provided on 8/26/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for HPV. The physician reviewer found that according to the recommendations from the American College of Obstetrics and Gynecology (ACOG) and the American Society for Colposcopy and Cervical Pathology (ASCCP), women aged 21-29 years should have a Pap test alone every three years and HPV testing is not recommended. The guidelines further recommended that women ages 30-65 years should have a Pap test and an HPV test (co-testing) every five years. It also is acceptable to have a Pap test alone every three years. From the chart and patient statements, the HPV testing performed at this patients postpartum visit was not clinically indicated for evaluation of this patients medical condition. There was no medical record documenting any previous normal or abnormal Pap smear testing. Overall, the current guidelines only support an indication for the Pap smear, not the HPV testing. Thus, the HPV testing provided on 8/26/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 0 |
The parent of a 14-year-old male enrollee has requested authorization and coverage for surgery for scoliosis. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.
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Upheld
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Experimental
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Summary Reviewer 3
The parent of a 14-year-old male enrollee has requested authorization and coverage for surgery for scoliosis. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that standard interventions for adolescents and adults, including spinal deformity correction and fusion, may not be appropriate for young patients with considerable growth remaining. Preliminary outcomes for fusionless spine surgery are promising, but further investigation, including long-term follow-up, is necessary. In addition, the requested technique is not the standard of care in this clinical setting. Vertebral body stapling, a fusionless treatment option, has been shown to be effective in controlling curve progression in the high-risk group of children younger than 10 years with idiopathic scoliosis between 30 and 39 degrees in whom bracing may be ineffective (Theologis, et al). Therefore, surgery for scoliosis 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.
| 0 |
A 58-year-old female enrollee has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD) and esophagitis.
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Upheld
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Experimental
|
Summary Reviewer 1
A 58-year-old female enrollee has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD) and esophagitis. The physician reviewer found that overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al; Ganz). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the requested LINX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 1 |
A 46-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the patient has obstructive sleep apnea. The drug induced sleep endoscopy showed no concentric collapse at velum and primarily anterior posterior collapse at the velum and tongue base/epiglottis. The patient has not been able to tolerate the APAP device. The Inspire device has been
this point, the patient is a candidate for the Inspire device, given the intolerance to APAP, anterior posterior collapse, no central apnea, and body mass index
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Overturned
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Experimental
|
Summary Reviewer 1
A 46-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the patient has obstructive sleep apnea. The drug induced sleep endoscopy showed no concentric collapse at velum and primarily anterior posterior collapse at the velum and tongue base/epiglottis. The patient has not been able to tolerate the APAP device. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device, given the intolerance to APAP, anterior posterior collapse, no central apnea, and body mass index (BMI) and apnea-hypopnea index (AHI) within FDA criteria. There is sufficient support for the requested services in this clinical setting. Therefore, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be more beneficial than other available standard therapy.
| 1 |
patient is a 31-year-old female with a history of vitiligo. She was previously treated with narrowband ultraviolet B (UVB) without success.
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Overturned
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Medical Necessity
|
Summary Reviewer
The patient is a 31-year-old female with a history of vitiligo. She was previously treated with narrowband ultraviolet B (UVB) without success. The physician reviewer found that Vitiligo is an autoimmune disease, evidenced by circulating melanocyteaspecific antibodies, and association with other autoimmune diseases. At present, no medical treatment for repigmenting vitiligo has been approved by the U.S. Food and Drug Administration (FDA), and therefore treatments are used off-label. Topical treatments may be applied alone when small areas are involved or when other treatment modalities are not readily available. This patient has failed to repigment with topical treatment alone. Phototherapy combined with topical treatment is preferred when greater than 5-10% of the body surface area is affected. The use of targeted phototherapy, excimer laser, is preferred when there is limited disease, as this limits the exposure of the skin from unwanted side effects of total body ultraviolet treatment. Targeted narrowband UVB in the form of excimer laser is considered standard therapy. Therefore, CPT codes 96920, 96921 and 96922 (laser treatment for skin disease) are medically necessary for the treatment of this patient.
| 1 |
A 27-year-old male enrollee has requested reimbursement for laboratory services (81243, 88230, 88262, 88289) provided 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 laboratory services in dispute are 88230, tissue culture for non-neoplastic disorders, lymphocyte, 88262, chromosome analysis, count 15-20 cells, two karyotypes, with banding, 88289, chromosome analysis, additional high resolution study, and 81243, fragile X (FMR1
. The providers notes state that this was ordered due to the patients sisters infertility and his mothers miscarriages.
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Upheld
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Medical Necessity
|
Summary Reviewer
A 27-year-old male enrollee has requested reimbursement for laboratory services (81243, 88230, 88262, 88289) provided 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 there is a lack of support for the services at issue in this clinical setting. Per the records, the laboratory services in dispute are 88230, tissue culture for non-neoplastic disorders, lymphocyte, 88262, chromosome analysis, count 15-20 cells, two karyotypes, with banding, 88289, chromosome analysis, additional high resolution study, and 81243, fragile X (FMR1). Codes 88230, 88262 and 88289 can be grouped together, as the tissue culture is needed for chromosome analysis. In this patients case, it is unclear why the provider ordered both standard chromosome analysis and high resolution chromosome analysis, but neither were indicated. The providers notes state that this was ordered due to the patients sisters infertility and his mothers miscarriages. Either of these would be indications for chromosome analysis in the affected individual, but are not indications for analysis in this patient. With regards to 81243, the notes indicate that this was ordered due to a history of anxiety, depression, and obsessive-compulsive disorder in the patient, family history of autistic-like behaviors in the patients brother, and family history of psychiatric illness. This testing was not indicated. Fragile X is a common cause of significant intellectual disability and autism spectrum disorders, not reported in this patient (or his brother with autistic-like behaviors but high intelligence). Males with fragile X will have significant developmental concerns, which this patient does not have. Psychiatric illness alone is not caused by fragile X full mutations or pre-mutations. While his sisters infertility may be an indication for testing her if she has premature ovarian failure, testing this patient was not indicated. Therefore, laboratory services (81243, 88230, 88262 and 88289) provided on 10/19/18 were not medically necessary for the evaluation of this patient.
| 1 |
A 26-year-old male enrollee has requested authorization and coverage for Ocrevus injections 300/10 mL. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees relapsing-remitting multiple sclerosis.
. The Health Insurer has offered glatiramer acetate and fingolimod (Gilenya) as alternatives. However, this patient has reportedly failed a trial of glatiramer acetate. The records document that the patient tested positive for JC virus.
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Overturned
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Medical Necessity
|
Summary Reviewer
A 26-year-old male enrollee has requested authorization and coverage for Ocrevus injections 300/10 mL. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees relapsing-remitting multiple sclerosis. The physician reviewer found the submitted documentation supports the medical necessity of the requested medication. The Health Insurer has offered glatiramer acetate and fingolimod (Gilenya) as alternatives. However, this patient has reportedly failed a trial of glatiramer acetate. The records document that the patient tested positive for JC virus. Medications such as Gilenya and Tysabri are contraindicated for patients with positive JC virus titers. There is greater potential for risk of progressive multifocal leukoencephalopathy, an often opportunistic infection from JC virus, in patients treated with Gilenya. The current medical evidence supports the requested medication in this patients case. All told, Ocrevus injections 300/10 mL are medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| 1 |
A 75-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing
performed on 5/26/21. The Health Insurer has denied this request and reported that the
services at issue were investigational for the evaluation of the enrollees medical condition.
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Upheld
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Experimental
|
Summary Reviewer 3
A 75-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing
performed on 5/26/21. The Health Insurer has denied this request and reported that the
services at issue were investigational for the evaluation of the enrollees medical condition. The
physician reviewer found that per the National Comprehensive Cancer Network guidelines, the
recommended therapy for stage IB cutaneous melanoma is history and physical and only
imaging to evaluate certain signs and symptoms. The recommended primary category 1A
treatment is wide excision of the melanoma and to discuss and offer sentinel lymph node
biopsy. Furthermore, the guidelines state, For stage IB (pT2a) melanoma, the probability of a
positive sentinel lymph node is greater than 10%. There is no indication for a gene expression
assay to determine the primary course of treatment as sentinel lymph node biopsy should be
offered with the above case. Marchetti and colleagues concluded, The prognostic ability of
GEP tests among patients with localized melanoma varied by AJCC stage and appeared to be
poor at correctly identifying recurrence in patients with stage I disease, suggesting limited
potential for clinical utility in these patients. Therefore, DecisionDx-Melanoma testing
performed on 5/26/21 was not likely to have been more beneficial than any available standard
therapy.
| 0 |
A 26-year-old female enrollee has requested reimbursement for CPT code 81291 performed on 10/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a family history of a clotting disorder.
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Upheld
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Experimental
|
Summary Reviewer 3
A 26-year-old female enrollee has requested reimbursement for CPT code 81291 performed on 10/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a family history of a clotting disorder. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Knowledge of the patients MTHFR status does not impact her care during pregnancy. All pregnant patients are advised to have adequate folic acid intake to prevent neural tube defects. There is no recommended treatment during pregnancy for a known mutation in the MTHFR gene. Thus, the superior efficacy of CPT code 81291 performed on 10/11/17 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.
| 0 |
A 59-year-old male enrollee has requested reimbursement for the UroLift procedure performed on 4/3/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees elevated prostate specific antigen (PSA) and enlarged prostate with lower urinary tract symptoms.
This patient was initially evaluated for erectile dysfunction.
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Overturned
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Experimental
|
Summary Reviewer 2
A 59-year-old male enrollee has requested reimbursement for the UroLift procedure performed on 4/3/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees elevated prostate specific antigen (PSA) and enlarged prostate with lower urinary tract symptoms. The physician reviewer found that the UroLift procedure has been approved as an effective treatment of appropriately selected patients 50 years or over with BPH. UroLift has shown to be successful and relatively safe in the short-term. There is good quality evidence to establish the efficiency of UroLift in treating symptomatic BPH without adversely affecting the quality of life. Based on the current literature, UroLift can be considered as an option for those symptomatic BPH patients with small or medium size prostates defined as less than 80 mL without median lobe enlargement, who failed on medical therapy or are intolerant to it and wish to preserve their sexual function. This patient was initially evaluated for erectile dysfunction. All told, the UroLift procedure performed on 4/3/17 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 service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| 1 |
A 43-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 7/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.
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Overturned
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Experimental
|
Summary Reviewer 2
A 43-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 7/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that Foundation One assay is a molecular assay of gene mutations found in a variety of cancer cells. The hope is that the assay will identify a specific mutation or target that could guide the clinician as to which chemotherapeutic drug would be useful. Thus far, there is a lack of convincing evidence that the assay adds to the decision making ability or yields a result that is clinically beneficial. Le Tourneau and colleagues did not demonstrate better efficacy when choosing therapy based on such an assay versus the oncologists clinical judgment. In this patients case, the initial treatment was based on the oncologist common practice without the need for Foundation One assay results. In sum, FoundationOne CDx testing performed on 7/16/19 was not likely to have been more beneficial than other methods of evaluating this patient.
| 0 |
A 61-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 colorectal cancer with liver metastases.
|
Upheld
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Experimental
|
Summary Reviewer 3
A 61-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 colorectal cancer with liver metastases. The physician reviewer found that the potential benefit of proton therapy over photon therapy lies in its potential ability to spare normal tissue adjacent to the treatment volume. While proton therapy appears superior to photon therapy dosimetrically, it does not always translate into a clinical benefit. There is a paucity of randomized or retrospective trials supporting proton therapy in the treatment of rectal cancer. The lack of studies for proton cancer in rectal cancer is likely due to the fact that proton therapy excels in clinical scenarios where there is a sharp border between the radiation target and normal tissue, especially if it occurs in a tight space. This is not the clinical scenario for rectal cancer. The treatment volume for rectal cancer is relatively large, and includes the entire rectum and the mesorectum. The main acute side effect of radiotherapy for rectal cancer is diarrhea, and is due to the fact the entire rectum receives the full dose of radiation. Because the rectum is the target of radiotherapy, it is not possible nor desirable to spare the rectum from radiation. The other structures that may be of concern in sparing for rectal radiation are the small bowel and bladder. Given that the dose tolerance for the small bowel is 50 Gy, and that the dose required in a palliative setting should be below 50 Gy, there is no perceived benefit to proton therapy in sparing the small bowel from a dose below tolerance. Moreover, proton therapy is not recommended in the National Comprehensive Cancer Network (NCCN) guidelines for rectal cancer. For these reasons, 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 |
A 36-year-old male enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees sleep apnea.
With a BMI of 31.9, AHI of 43.9 and nonconcentric airway collapse, this patient meets the criteria. He has failed CPAP which is the gold standard treatment for OSA and has also failed upper airway sleep surgery. He remains at risk for
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Overturned
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Experimental
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Summary Reviewer 3
A 36-year-old male enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees sleep apnea. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. OSA is an increasingly prevalent clinical problem. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The Stimulation Therapy for Apnea Reduction (STAR) trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA (Woodson, et al). This trial demonstrated that hypoglossal nerve stimulator is safe and effective in a small subset of patients with OSA who have failed CPAP. With a BMI of 31.9, AHI of 43.9 and nonconcentric airway collapse, this patient meets the criteria. He has failed CPAP which is the gold standard treatment for OSA and has also failed upper airway sleep surgery. He remains at risk for untoward cardiac sequelae of untreated OSA. All told, implantation with a hypoglossal nerve stimulator is likely to be of greater benefit than the standard modalities for treatment of this patients medical condition. Therefore, for the reasons stated 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 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes.
the patient is a 60-year-old female with infrequent syncope recently resulting in head trauma and negative short-term evaluation for culprit arrhythmias.
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Overturned
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Experimental
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Summary Reviewer 1
A 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes. The physician reviewer found that based on the records provided the patient is a 60-year-old female with infrequent syncope recently resulting in head trauma and negative short-term evaluation for culprit arrhythmias. In this setting, prolonged monitoring for a dysrhythmic cause of the patients syncope is reasonable, appropriate and considered standard accepted practice in the medical community. Prolonged monitoring cannot be feasibly obtained with any monitoring device other than an implantable device such as a LINQ monitor. This approach has shown to be more effective than standard monitoring in identification of a cause and is now incorporated into current guidelines (Strickberger, et al; Krahn, et al; Brignole, et al). Therefore, the request for a heart monitor (implantable ambulatory event monitor) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested device 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 parent of an eight-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy, 13 hours per month of supervision and four hours per month of parent training provided from 4/29/16 through 10/29/16. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism spectrum disorder.
In this case, the patient is in the first grade and is already having a school day of at least six hours.
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Overturned
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Medical Necessity
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Summary Reviewer
The parent of an eight-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy, 13 hours per month of supervision and four hours per month of parent training provided from 4/29/16 through 10/29/16. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism spectrum disorder. The physician reviewer found that a nonsystematic review concluded that for best practice a minimum of 20 hours a week of intervention over two years, taking account of each childs strengths and weaknesses and family circumstances, was essential for young children with autism to make gains (Smith, et al; Roberts). In this case, the patient is in the first grade and is already having a school day of at least six hours. The request for 40 hour per week of ABA is excessive and may be detrimental of the desired effect. Therefore, based upon the medical literature and the documentation submitted for review, 20 hours per week of ABA therapy, 13 hours per month of supervision and four hours per month of parent training provided from 4/29/16 through 10/29/16 were and are medically necessary for treatment of the patients medical condition. Therefore, a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
| 1 |
A 21-year-old male enrollee has requested reimbursement for polymerase chain reaction testing performed on 6/07/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.
this patient appears to have had chronic prostatitis and was evaluated and treated with several antibiotic regimens. Per the records, gonorrhea and chlamydia testing was negative. His symptoms seem to improve, but returned after cessation of antibiotics. The urine was then sent for DNA analysis.
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Upheld
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Experimental
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Summary Reviewer 2
A 21-year-old male enrollee has requested reimbursement for polymerase chain reaction testing performed on 6/07/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient appears to have had chronic prostatitis and was evaluated and treated with several antibiotic regimens. Per the records, gonorrhea and chlamydia testing was negative. His symptoms seem to improve, but returned after cessation of antibiotics. The urine was then sent for DNA analysis. It is standard of care to obtain bacterial, viral and fungal cultures for the diagnosis and management of prostatitis. DNA analysis is not the standard of care for this evaluation. In sum, polymerase chain reaction testing performed on 6/07/19 was not likely to have been more beneficial than other methods of evaluating this patient.
| 1 |
A 39-year-old male enrollee has requested authorization and coverage for Xeljanz. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition.
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Overturned
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Experimental
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Summary Reviewer 3
A 39-year-old male enrollee has requested authorization and coverage for Xeljanz. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that available treatment options for alopecia areata are quite limited. This is especially true for diffuse/multifocal involvement, where standard therapies such as topical steroids, intralesional Kenalog, contact immunotherapy and conventional immunosuppressants are more often than not less than satisfactory and associated with side effects. Although there is no significant data yet from randomized clinical trials (which are currently underway), there is substantial clinical evidence to support the use of oral Janus kinase inhibitors such as tofacitinib for alopecia areata. In one open label pilot study, eight of 12 patients demonstrated approximately 50% hair regrowth as measured by Severity in Alopecia Tool (SALT) scoring. There have been minimal adverse effects reported to date. Moreover, these results are better than what has been reported for contact immunotherapy and systemic steroids. Therefore, Xeljanz is likely to be more beneficial than other available standard therapy.
| 1 |
A 30-year-old female enrollee has requested authorization and coverage for Butrans. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees pain.
requested medication. The Health Insurer has denied coverage for Butrans. The Health Insurer requires history of failure or intolerance
drugs. These are Belbuca, tramadol extended release, and morphine sulfate controlled release tablets.
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Upheld
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Medical Necessity
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Summary Reviewer
A 30-year-old female enrollee has requested authorization and coverage for Butrans. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees pain. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. The Health Insurer has denied coverage for Butrans. The Health Insurer requires history of failure or intolerance to the step one alternative drugs. These are Belbuca, tramadol extended release, and morphine sulfate controlled release tablets. In this patients case, a trial of Belbuca is medically appropriate and reasonable. Belbuca is the same drug as the patient is requesting, but in a form that dissolves in the buccal cavity. It is approved by the U.S. Food and Drug Administration for treating severe pain. Similar to Butrans, Belbuca has been shown to have efficacy and safety in chronic pain patients. Additional studies support the efficacy of Belbuca in this clinical setting. All told, Butrans is not medically necessary for the treatment of this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
A 26-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment provided from 1/28/18 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions.
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Upheld
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Medical Necessity
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Summary Reviewer
A 26-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment provided from 1/28/18 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to lack of suicidal ideation. With regards to functional status, the records support a score of 3 due to overall fair functional level at home with some issues with daily activities. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and some history of substance use issues. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living environment with family members. In terms of level of support of the recovery environment, the records support a score of 2 due to an overall supportive recovery environment and family that is supportive of his treatment. With regards to treatment and recovery history, the records support a score of 3 due to moderate response to past treatment. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment. Thus, the patient has a composite score of 15. This score correlates with low-intensity community-based services. Therefore, the records do not demonstrate the medical necessity of residential treatment. In sum, residential treatment from 1/28/18 and ongoing was not and is not medically necessary for the treatment of this patient.
| 0 |
A 46-year-old female enrollee has requested authorization and coverage for total disc arthroplasty (CPT 22858 and 22856). 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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Overturned
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Experimental
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Summary Reviewer 2
A 46-year-old female enrollee has requested authorization and coverage for total disc arthroplasty (CPT 22858 and 22856). 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 the current medical evidence supports the requested services in this clinical setting. This particular implant has been approved for two-level use. Most of the literature indicates an initial advantage to cervical disc replacement compared to anterior cervical discectomy and fusion. However, long-term results of both procedures are similar or there is a slight advantage to total disc arthroplasty. Davis and colleagues noted that four-year results from their study continued to support total disc replacement as a safe, effective, and statistically superior alternative to anterior cervical discectomy and fusion for the treatment of degenerative disc disease at two contiguous cervical levels. In sum, the requested total disc arthroplasty is likely to be of greater benefit than other treatment options. Therefore, as 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.
| 0 |
The patient is a 61-year-old female diagnosed with attention deficit hyperactivity disorder (ADHD), binge eating disorder and malabsorption syndrome status-post gastric bypass surgery. The patient had reportedly been on lisdexamfetamine (Vyvanse) since 2012. In 2017, it appears that medication became less effective, lasting no more than four hours. On Vyvanse 70 mg three times a day (TID), the dose was well tolerated, with no insomnia or other side effects. The patient has requested authorization and coverage for Vyvanse 70 mg TID. The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational.
Stimulant
for ADHD. This patients records document that she has been diagnosed with ADHD and binge eating disorder. The current dose of Vyvanse was achieved after a systematic reasonable titration due to her comorbid conditions.
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Overturned
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Experimental
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Summary Reviewer 2
The patient is a 61-year-old female diagnosed with attention deficit hyperactivity disorder (ADHD), binge eating disorder and malabsorption syndrome status-post gastric bypass surgery. The patient had reportedly been on lisdexamfetamine (Vyvanse) since 2012. In 2017, it appears that medication became less effective, lasting no more than four hours. On Vyvanse 70 mg three times a day (TID), the dose was well tolerated, with no insomnia or other side effects. The patient has requested authorization and coverage for Vyvanse 70 mg TID. The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational.
Stimulant medications, like Vyvanse, are first-line therapies for ADHD. This patients records document that she has been diagnosed with ADHD and binge eating disorder. The current dose of Vyvanse was achieved after a systematic reasonable titration due to her comorbid conditions. The decreased bioavailability and lowered absorption of orally administered drugs in this clinical setting is common due to the bypassing of the duodenum, proximal jejunum and majority of the stomach. The medication dose appears to be both efficacious and well-tolerated, with no evidence that it is unsafe. The medication is approved by the FDA for the conditions being treated. The treatment is optimizing functionality and minimizing the patients illness burden. It is the recommendation of the treating provider to continue the medication at the current dose. The patient desires to continue the treatment. Considering all aspects of this patients case, the requested Vyvanse 70 mg TID is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication dosage 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 |
patient is a 61-year-old male. In a letter dated 12/8/22, the provider reported that the patient
presented with a variety of neurological symptoms and was initially evaluated in Japan in August
2018 with a diagnostic angiogram that showed a lesion. The patient has requested authorization
and coverage for the PET with CT scan. 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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Overturned
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Medical Necessity
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Summary
The patient is a 61-year-old male. In a letter dated 12/8/22, the provider reported that the patient
presented with a variety of neurological symptoms and was initially evaluated in Japan in August
2018 with a diagnostic angiogram that showed a lesion. The patient has requested authorization
and coverage for the PET with CT scan. The Health Insurer has denied this request and reported
that the requested services are not medically necessary for the evaluation of this patient. This denial
is the subject of this appeal and determination. The physician reviewer found that the submitted
documentation supports the medical necessity of the requested services. PET-CT scans are
invaluable in determining whether a skull base lesion is of neoplastic origin or vascular origin. The
surgical approach and treatment of these two possibilities are vastly differently so as to profoundly
increase the importance of accurate, pre-intervention diagnosis. Chang and colleagues note that
combined with high specificity and patient convenience, dotatate PET/CT should be considered
the ideal first line investigation for imaging neuroendocrine tumors. In this clinical setting, given
that current medical literature supports the use of dotatate PET/CT in a standard work-up of this
patient, the requested services are medically indicated. Therefore, the PET with CT scan is
medically necessary for the evaluation of this patient.
| 1 |
A 52-year-old male enrollee has requested reimbursement for ExoDx Prostate/ExosomeDx
Prostate (Intelliscore) performed on 12/23/20. The Health Insurer has denied this request and
reported that the services at issue were investigational for the evaluation of the enrollees
medical condition.
. This patient has risk factors for
developing prostate cancer.
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Overturned
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Experimental
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Summary Reviewer 3
A 52-year-old male enrollee has requested reimbursement for ExoDx Prostate/ExosomeDx
Prostate (Intelliscore) performed on 12/23/20. 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 ExoDx Prostate/ExosomeDx Prostate
(Intelliscore) is a noninvasive liquid biopsy that quantifies three RNA targets in urine exosomes.
The urine exosome gene expression assay is associated with improved identification of patients
with higher-grade prostate cancer among men with elevated PSA levels and could reduce the
total number of unnecessary biopsies. Despite these findings, currently there is not enough
clinical evidence that this testing can be utilized instead of prostate biopsy to diagnose prostate
cancer. This patients prostate ultrasound was unremarkable. This patient has risk factors for
developing prostate cancer. Furthermore, PSA levels can be misleading due to testosterone
replacement therapy. There is a lack of support for the services at issue in this clinical setting.
Therefore, ExoDx Prostate/ExosomeDx Prostate (Intelliscore) performed on 12/23/20 was not
likely to have been more beneficial than any available standard therapy.
| 1 |
A 32-year-old male enrollee has requested authorization and coverage for RT300 therapy system. 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.
In this case, the patient had bilateral brainstem strokes in 2011, which is the
a locked-in state. As of May 2016, he had recovered to a level where he had essentially normal left upper limb strength. He had weak but functional right upper limb strength. He was able to perform some functional tasks with assistance. He was mute/aphonic, but communicating with the assistance of an application on his mobile phone.
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Upheld
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Medical Necessity
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Summary Reviewer
A 32-year-old male enrollee has requested authorization and coverage for RT300 therapy system. 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 Locked-in syndrome is a very rare condition characterized by paralysis of almost all muscles that are under voluntary control (except, classically, for the muscles responsible for vertical eye movements), while consciousness and cognition remain intact. The condition is often mistaken for a vegetative state. In this case, the patient had bilateral brainstem strokes in 2011, which is the typical etiology responsible for a locked-in state. As of May 2016, he had recovered to a level where he had essentially normal left upper limb strength. He had weak but functional right upper limb strength. He was able to perform some functional tasks with assistance. He was mute/aphonic, but communicating with the assistance of an application on his mobile phone. The patients most recently described functional status in the available documentation is not compatible with persistent locked-in syndrome. An upper body functional electrical stimulation cycle ergometer has been recommended for the patient. There is no indication, however, that the patient could not use a standard upper body cycle ergometer for exercise, i.e., without the functional electrical stimulation component. There is some weakness in the right upper limb, but left upper limb strength is essentially intact. There is a lack of published data that establish a benefit of use of the device in question for the patients condition. It is not a proven adjunct or substitute for active exercise using volitionally intact muscles in the setting of this patients condition. It is not reasonably expected to improve function, health or incidence of complications. Therefore, the requested RT300 therapy system is not medically necessary for the treatment of this patient.
| 1 |
A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 4/12/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.
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Upheld
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Experimental
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Summary Reviewer 3
A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 4/12/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. As the records do not document that the patient underwent a sentinel node procedure, it cannot be determined whether the patient had stage I/II/II disease. The proposed clinical utility of the DecisionDx-Melanoma assay applies to pathologically confirmed stage I/II/III. Therefore, DecisionDx-Melanoma assay was not likely to have been beneficial for this patients medical condition, as it has not been determined that he had the correct stage of disease due to the lack of lymph node staging. Thus, DecisionDx-Melanoma assay performed on 4/12/18 was not likely to have been superior over other methods of evaluating this patient.
| 0 |
An 81-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/27/18. 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 2
An 81-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/27/18. 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 the current medical evidence does not support the services at issue in this clinical setting. 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. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. In sum, DecisionDx-Melanoma testing performed on 2/27/18 was not likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 0 |
The parent of a 17-year-old male enrollee has requested authorization and coverage for Nutropin. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature.
the records provided for review document that this patient has been receiving GH therapy for GH deficiency.
, the patient still has open epiphyses and continues to grow at a growth rate that is
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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 authorization and coverage for Nutropin. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature. The physician reviewer found that the records provided for review document that this patient has been receiving GH therapy for GH deficiency. Based on current guidelines from the Lawson Wilkins Pediatric Endocrinology Society Drug and Therapeutics Committee and American Association of Clinical Endocrinologists, continuation of therapy is medically necessary until epiphyseal fusion and/or until growth velocity is less than 2 cm per year. Based on the report from the most recent examination by the patients provider in January 2016, the patient still has open epiphyses and continues to grow at a growth rate that is greater than 2 cm per year. Thus, the requested GH therapy with Nutropin is medically necessary for this patient. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| 1 |
The parent of a 14-year-old female enrollee has requested authorization and coverage for colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic
), with interpretation and report, procedure code 91117, and associated one day inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollee, who has a history of bowel incontinence. The physician reviewer found that this patient has been diagnosed with Phelan-McDermid syndrome.
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Overturned
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Experimental
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Summary Reviewer 3
The parent of a 14-year-old female enrollee has requested authorization and coverage for colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report, procedure code 91117, and associated one day inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollee, who has a history of bowel incontinence. The physician reviewer found that this patient has been diagnosed with Phelan-McDermid syndrome. Patients with this condition have a wide range of medical, intellectual and behavioral challenges. Gastrointestinal issues are common and include reflux, vomiting, diarrhea, constipation and hypotonia. Manometry studies help in understanding the pathophysiology of the defection disorders in these children. Studies have shown that surgical interventions in these patients, as guided by manometric findings, have led to improvement in patient outcome and quality of life. The requested services are an appropriate next step for this patient with intractable constipation and stool incontinence. Thus, colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report, procedure code 91117, and associated one day inpatient admission are likely to be more effective than other methods of evaluating this patient. Based upon the information set forth above, the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| 1 |
A 22-year-old male enrollee has requested reimbursement for surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees hip pain.T
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Overturned
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Experimental
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Summary Reviewer 3
A 22-year-old male enrollee has requested reimbursement for surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees hip pain.The physician reviewer found that surgical treatment of symptomatic femoroacetabular impingement aims to improve symptoms and potentially delay hip osteoarthritis and prevent the need for a possible total hip arthroplasty. Hip arthroscopy and open surgical hip dislocations are the two most common surgical approaches used for this condition. The arthroscopic procedure avoids some of the complications of open surgery, but both approaches result in over 75% good to excellent results. Femoroacetabular impingement may be of the cam or pincer-type, or it may be mixed as in this case. Surgery is recommended when the degenerative changes are mild or absent, as in this case with documented failure of conservative treatment. The current medical literature indicates that arthroscopic surgery for femoroacetabular impingement has a known excellent outcome in the majority of individuals. Thus, surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15 was likely to have been of greater benefit than other treatment alternatives. 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 |
The patient is a 57-year-old male who presented with a prostate-specific antigen (PSA) of 7.0. The patient has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.
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Upheld
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Medical Necessity
|
Summary Reviewer
The patient is a 57-year-old male who presented with a prostate-specific antigen (PSA) of 7.0. The patient has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The patientas history of hemochromatosis is not sufficient to support the use of proton beam therapy for his prostate cancer. There is a lack of strong medical evidence to suggest that treatment with proton beam therapy is associated with a clinical benefit compared to standard treatment. Furthermore, proton beam therapy has not been validated in a comparative randomized study to standard treatment with photons. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer and compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. The American Society of Radiation Oncology (ASTRO) stated, aProton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry.a ASTRO notes that the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity modulated radiation therapy technique. Therefore, the requested proton beam therapy is not medically necessary for the treatment of this patient.
| 1 |
A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for the enrollees gastroesophageal reflux disease (GERD).
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Upheld
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Experimental
|
Summary Reviewer 1
A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the U.S. Food and Drug Administration (FDA) has approved the LINX Reflux Management System for the treatment of lower esophageal sphincter augmentation. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter (LES) closure pressure, but allow for food passage with swallowing. Reynolds and colleagues performed a study comparing the LINX procedure with laparoscopic fundoplication was performed which used propensity matching to compare groups. The authors found that GERD patients had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. In addition, a five-year cohort data was recently published establishing the durability of LINX. In a group of 85 patients augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux with minimal side effects or complications. Given the support cited above, the LINX procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Based upon the information set forth above, the requested procedure 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 34-year-old female enrollee has requested reimbursement for genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees pregnancy.
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Upheld
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Experimental
|
Summary Reviewer 2
A 34-year-old female enrollee has requested reimbursement for genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees pregnancy. The physician reviewer found that according to the American College of Obstetricians and Gynecologists (ACOG), screening for spinal muscular atrophy should be offered to all women who are considering pregnancy or are currently pregnant. However, the ACOG only recommends fragile X syndrome testing for patients with a family history of fragile X-related disorders or intellectual disability suggestive of fragile X syndrome and who are considering pregnancy or are currently pregnant or if a woman has unexplained ovarian insufficiency or failure or an elevated follicle-stimulating hormone level before age 40 years, fragile X carrier screening is recommended to determine whether she has an FMR1 premutation. In cases of this discordance, the patient should be referred to a genetics professional. However, the ACOG does not support an indication for genetic testing for fragile X syndrome in this clinical setting. For these reasons, the genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17 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.
| 0 |
A 47-year-old female enrollee has requested reimbursement and prospective authorization and coverage for pertuzumab injections from 8/18/15 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered 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 47-year-old female enrollee has requested reimbursement and prospective authorization and coverage for pertuzumab injections from 8/18/15 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found pertuzumab has been shown to increase pathologic complete responses in patients with HER2 positive breast cancer. Pertuzumab is recommended for neoadjuvant therapy for four to six cycles, and if not given in the neoadjuvant setting, may be given for four to six cycles as adjuvant therapy. However, there is a lack of support for adjuvant therapy with pertuzumab in this clinical setting. Therefore, pertuzumab injections from 8/18/15 forward were not and are not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 27-year-old female insured has requested authorization and coverage for Besremi 500 mcg/mL
syringe. A review of the record indicates the insured is currently pregnant and has a history of
essential thrombocythemia. The Health Insurer indicates the requested treatment is considered
investigational for the treatment of the insureds medical condition. Therefore, the Health Insurer
has denied coverage for the requested treatment.
that
this patient presents with low-risk Janus kinase 2 (JAK2)-positive essential thrombocytosis. Per
the provider, the patient does not have a prior history of thrombotic complications. The patient
was started on Pegasys after she became pregnant. The patient has reportedly tolerated treatment
with Pegasys other than injection site pain. The patients provider has recommended treatment
with Besremi.
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Overturned
|
Experimental
|
Summary Reviewer 1
A 27-year-old female insured has requested authorization and coverage for Besremi 500 mcg/mL
syringe. A review of the record indicates the insured is currently pregnant and has a history of
essential thrombocythemia. The Health Insurer indicates the requested treatment is considered
investigational for the treatment of the insureds medical condition. Therefore, the Health Insurer
has denied coverage for the requested treatment. This denial is the subject of this appeal and
determination. The physician reviewer found that the records provided for review document that
this patient presents with low-risk Janus kinase 2 (JAK2)-positive essential thrombocytosis. Per
the provider, the patient does not have a prior history of thrombotic complications. The patient
was started on Pegasys after she became pregnant. The patient has reportedly tolerated treatment
with Pegasys other than injection site pain. The patients provider has recommended treatment
with Besremi. However, The U.S. Food and Drug Administration (FDA) has not approved
Besremi in the setting of essential thrombocytosis. Moreover, Besremi has not been listed on the
National Comprehensive Cancer Network (NCCN) guideline as a recommended therapy option
for patients with essential thrombocytosis. Therefore, the requested Besremi 500 mcg/mL
syringe is not likely to be more beneficial for the treatment of the patients medical condition
than any available standard therapy.
| 1 |
A 58-year-old male enrollee has requested authorization and coverage for epidural steroid injections. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.
|
Upheld
|
Medical Necessity
|
Summary Reviewer
A 58-year-old male enrollee has requested authorization and coverage for epidural steroid injections. 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 that the submitted documentation fails to demonstrate the medical necessity of the requested services. The patients physical examination and lumbar magnetic resonance imaging (MRI) do not show evidence of lumbar radiculopathy/radiculitis. The peer-reviewed medical literature provides evidence for epidural steroid injections in documented cases of nerve root compression or radiculitis. The patients chronic pain condition is not consistent with such a diagnosis. There is a lack of support for the requested services in this clinical setting. All told, the requested epidural steroid injections are not medically indicated for the treatment of this patient. Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| 0 |
patient is a 63-year-old male who has a history of back pain. The patient has requested
authorization and coverage for MRI of the lumbar spine.
|
Upheld
|
Medical Necessity
|
Summary Reviewer
The patient is a 63-year-old male who has a history of back pain. The patient has requested
authorization and coverage for MRI of the lumbar spine. The physician reviewer found that the
submitted documentation fails to demonstrate the medical necessity of the requested services.
According to the American College of Radiology (ACR), In the absence of red flags, first-line
treatment for chronic low back pain remains conservative therapy with both pharmacologic
and non-pharmacologic (e.g., exercise, remaining active) therapy. However, patients presenting
with subacute or chronic low back pain, with or without radiculopathy, who have failed six
weeks of conservative therapy should be imaged if they are believed to be candidates for surgery
or intervention or if diagnostic uncertainty remains. The goal of imaging is to identify potential
actionable pain generators that could be targeted for intervention or surgery. The current
documentation indicates that physical therapy was done in 2019, but the records do not
document more recent failure of physical therapy. There is no documentation of a surgical
consultation with plan for invasive therapy. The records do not document neurological deficits.
Therefore, the requested MRI of the lumbar spine is not medically necessary for the evaluation
of this patient.
| 1 |
patient is a 55-year-old female with duplex documented right great saphenous vein reflux and a vein measuring greater than 6 mm at the saphenofemoral junction and further down the thigh. She has completed conservative measures and has had previous interventions. The patient has requested authorization and coverage for varicose vein surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.
tic. Additionally, the records document a prior course of conservative treatment. Per the records, her prior treatment included compression hose, elevation, exercise and Motrin.
|
Overturned
|
Medical Necessity
|
Summary Reviewer
The patient is a 55-year-old female with duplex documented right great saphenous vein reflux and a vein measuring greater than 6 mm at the saphenofemoral junction and further down the thigh. She has completed conservative measures and has had previous interventions. The patient has requested authorization and coverage for varicose vein surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. There is sufficient support for the requested services in this clinical setting. Despite prior interventions, this patient remains symptomatic. Additionally, the records document a prior course of conservative treatment. Per the records, her prior treatment included compression hose, elevation, exercise and Motrin. The medical evidence supports the requested services in this patients case. Thus, the requested varicose vein surgery is medically necessary for the treatment of this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| 1 |
A 54-year-old female enrollee has requested reimbursement for inpatient hospitalization provided from 3/31/17 through 4/07/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who sustained injuries when she fell off a horse. The physician reviewer found that this patient presented status post a traumatic fall from a horse resulting in severe back pain. Clinical examination findings were consistent with imaging evidence of L1 and L3 acute compression fractures. She had severe pain that was not controlled with oral medications. She was admitted for inpatient care for pain control and observation on 3/31/17. She was placed on bed rest with bracing ordered. She continued to require intravenous medication due to inadequate relief with oral medications. She was very limited in her activity due to severe pain. Given the failure of closed treatment with bracing and continued severe pain with associated functional limitations, she underwent L1 and L3 vertebroplasty on 4/04/17. Following this procedure, she was able to ambulate with physical therapy, and oral pain medications provided adequate control as of 4/07/17. She was discharged to home on 4/07/17 with
|
Overturned
|
Medical Necessity
|
Summary Reviewer
A 54-year-old female enrollee has requested reimbursement for inpatient hospitalization provided from 3/31/17 through 4/07/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who sustained injuries when she fell off a horse. The physician reviewer found that this patient presented status post a traumatic fall from a horse resulting in severe back pain. Clinical examination findings were consistent with imaging evidence of L1 and L3 acute compression fractures. She had severe pain that was not controlled with oral medications. She was admitted for inpatient care for pain control and observation on 3/31/17. She was placed on bed rest with bracing ordered. She continued to require intravenous medication due to inadequate relief with oral medications. She was very limited in her activity due to severe pain. Given the failure of closed treatment with bracing and continued severe pain with associated functional limitations, she underwent L1 and L3 vertebroplasty on 4/04/17. Following this procedure, she was able to ambulate with physical therapy, and oral pain medications provided adequate control as of 4/07/17. She was discharged to home on 4/07/17 with home health services. Evidence-based medical guidelines support hospitalization for parental narcotics and inability to manage basic activities of daily living at home, and additionally support a three-day best practice length of stay following vertebroplasty. Continued inpatient stay is supported until acceptable patient status for the next level of care is achieved, including pain is adequately managed on oral medications, and activity levels are at baseline or acceptable. Therefore, inpatient hospitalization provided from 3/31/17 through 4/07/17 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 68-year-old male enrollee has requested reimbursement for the positron emission tomography (PET) scan performed on 2/3/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees cognitive impairments, neuropsychiatric symptoms and parkinsonian features.
In this case, the patient was documented to have progressive cognitive decline with abnormal neuropsychological testing and no
|
Overturned
|
Experimental
|
Summary Reviewer 3
A 68-year-old male enrollee has requested reimbursement for the positron emission tomography (PET) scan performed on 2/3/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees cognitive impairments, neuropsychiatric symptoms and parkinsonian features. The physician reviewer found that although a PET scan is not indicated for every patient with progressive cognitive symptoms, it is useful and beneficial for a subset of patients suspected to have FTD versus AD. According to Foster and colleagues The addition of FDG-PET [positron emission tomography with 18F fluorodeoxyglucose] to clinical summaries increased diagnostic accuracy and confidence for both AD and FTD. It was particularly helpful when raters were uncertain in their clinical diagnosis. In this case, the patient was documented to have progressive cognitive decline with abnormal neuropsychological testing and no clear etiology determined by traditional testing. In cases such as this, it is essential to obtain the correct diagnosis to implement the proper treatment and avoid unnecessary treatments that may produce significant side effects. A PET scan is a reasonable medical approach to determine diagnosis and implement the proper therapy as AD and FTD are treated with different medical approaches. Therefore, the PET scan performed on 2/3/15 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 diagnostic procedure 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 |
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