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A 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral corneal ectasia. | Overturned | Experimental | Summary Reviewer 2
A 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral corneal ectasia. The physician reviewer found that Corneal crosslinking is a U.S. Food and Drug Administration (FDA) approved procedure for corneal ectasia and post refractive ectasia. The primary purpose of crosslinking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus and post refractive corneal ectasia. The procedure involves soaking the corneal stroma with riboflavin and then using ultraviolet light to create chemical bonds between collagen fibrils within the stroma. This stiffens the cornea and halts the thinning. Prior to this treatment, patients with keratoconus who failed medical treatment (glasses, contact lenses) and whose disease continued to progress would go on to surgical management with corneal transplantation. There have been multiple studies published which demonstrate that patients who underwent corneal crosslinking showed an improvement in keratometry values, uncorrected visual acuity and best corrected visual acuity in contrast to sham group. Of note, this procedure is not considered a refractive or vision correcting as the primary purpose of crosslinking is to stabilize the cornea and prevent further thinning and bulging that is seen with keratoconus and post refractive ectasias. In addition, there have been studies that have shown an overall decrease in the number of penetrating keratoplasties performed since the introduction of crosslinking. There is mounting evidence of the benefit of this treatment in patients diagnosed with keratoconus and post refractive ectasias who have progressive disease. Given the patients topographic evidence of post refractive ectasia, as well as the evidence of progressive disease, collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16 were likely to have been superior over any other methods for treatment of this patients medical condition. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| 1 |
A 64-year-old female enrollee has requested reimbursement for gene testing performed on 10/30/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 2
A 64-year-old female enrollee has requested reimbursement for gene testing performed on 10/30/17. 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 understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing to predict candidates for specific mutation-driven treatment holds promise but is not yet ready for routine clinical use. Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of next generation sequencing, such as with FoundationOne testing, continues to be the subject of ongoing clinical trials. In sum, gene testing performed on 10/30/17 was not likely to have been superior over other methods of evaluating this patient.
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The patient is a 33-year-old female who presented to her provider on 1/22/18. The records noted a body mass index of 41.1 kg/m2, consistent with obesity, and comorbidities including snoring/possible sleep apnea, and musculoskeletal pain. | Upheld | Medical Necessity | Summary Reviewer
The patient is a 33-year-old female who presented to her provider on 1/22/18. The records noted a body mass index of 41.1 kg/m2, consistent with obesity, and comorbidities including snoring/possible sleep apnea, and musculoskeletal pain. The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the requested services. No gastrointestinal symptoms are reported. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy recommend endoscopy for investigation of upper gastrointestinal symptoms when those symptoms are refractory to proton pump inhibitor taken properly for four to eight weeks without response, or for specific indications such as dysphagia. In this case, the provided information does not clearly document any such symptoms, or if symptoms were present, an attempt at treatment. The provider has not reported how management will change (i.e. surgery would be cancelled) based on findings. Endoscopy in asymptomatic patients before bariatric surgery has not been established as standard. Large studies have supported pre-surgery endoscopy only in symptomatic patients. For these reasons, esophagogastroduodenoscopy is not supported as medically necessary for the evaluation of this patients pre-bariatric surgery status in this case. Therefore, flexible esophagogastroduodenoscopy with biopsy performed on 3/03/18 was not medically necessary for the evaluation of this patient. | 1 |
A 35-year-old female enrollee has requested reimbursement for inpatient behavioral health services provided on 4/30/19 through 5/02/19. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees medical condition.
The records noted prior psychiatric hospitalizations, and the patient reportedly had been minimally engaged with outpatient psychiatry following discharge from her prior hospitalization. | Upheld | Medical Necessity | Summary Reviewer
A 35-year-old female enrollee has requested reimbursement for inpatient behavioral health services provided on 4/30/19 through 5/02/19. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees medical condition. 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 is indispensable in determining necessary level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no current suicidal or homicidal ideation, plan, intention or severe distress. With regards to functional status, the records support a score of 1 due to no problems with group attendance. Per the records, the patient found the groups to be supportive. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2. In terms of level of stress of the recovery environment, the records support a score of 1 due to a low stress environment. With regards to level of support for the recovery environment, the records support a score of 1 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 2 given her previous treatment. The records noted prior psychiatric hospitalizations, and the patient reportedly had been minimally engaged with outpatient psychiatry following discharge from her prior hospitalization. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment along with insight into her treatment needs. Thus, the patient has a composite score of 10. This correlates with treatment in a community-based outpatient clinic setting. Therefore, inpatient behavioral health services provided on 4/30/19 through 5/02/19 were not medically necessary for the treatment of this patient. | 1 |
A 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 3
A 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the superior efficacy of the services at issue has not been established. The patients history is not well-documented and does not indicate features of neuropathy. The examination was inadequate to discern if neuropathy was a realistic consideration. Electrodiagnostic test results were not submitted for review. If small fiber neuropathy is within the differential, commonly such individuals would be assessed by a neurologist familiar with neuropathy, and undergo more detailed neurologic clinical examination. 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 55-year-old female enrollee has requested reimbursement for CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition.
case, the patient has a history of mast cell disorder, multiple chemical sensitivities and food allergy. | Upheld | Experimental | Summary Reviewer 3
A 55-year-old female enrollee has requested reimbursement for CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found in this case, the patient has a history of mast cell disorder, multiple chemical sensitivities and food allergy. Allergen immunotherapy is a well-standardized treatment options. The current national guidelines indicate that allergen immunotherapy may be efficacious in the treatment of allergic rhinitis, allergic conjunctivitis, allergic asthma, and stinging insect hypersensitivity. In this case, there is no evidence of the above diagnoses. As such, CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15 was not likely to have been more efficacious than other treatment options. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 1 |
The patient is a 56-year-old male who presented on 7/31/16 with ventricular fibrillation due to an acute anterior myocardial infarction, requiring defibrillation prior to hospital arrival. He was found to have an occluded left anterior descending coronary artery on urgent catheterization and was treated with coronary stent placement. Within the next 24 hours, he had recurrent cardiac arrests due to polymorphic ventricular tachycardia thought to be related to ischemia. Repeat cardiac catheterization was performed, and balloon angioplasty to the left anterior descending preexisting stent and additional stent placement to a severe distal right coronary stenosis both were performed. There was no recurrent
ricular tachycardia, ventricular fibrillation or cardiac arrest after repeat coronary intervention on 8/01/16. He was discharged on 8/05/16. The patient has requested reimbursement for wearable cardioverter defibrillator. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of this patient. This patient presented with a cardiac arrest in the setting of acute myocardial infarction and then had recurrent ventricular tachycardia/cardiac arrest within the first 24 hours of infarction in | Upheld | Experimental | Summary Reviewer 2
The patient is a 56-year-old male who presented on 7/31/16 with ventricular fibrillation due to an acute anterior myocardial infarction, requiring defibrillation prior to hospital arrival. He was found to have an occluded left anterior descending coronary artery on urgent catheterization and was treated with coronary stent placement. Within the next 24 hours, he had recurrent cardiac arrests due to polymorphic ventricular tachycardia thought to be related to ischemia. Repeat cardiac catheterization was performed, and balloon angioplasty to the left anterior descending preexisting stent and additional stent placement to a severe distal right coronary stenosis both were performed. There was no recurrent sustained ventricular tachycardia, ventricular fibrillation or cardiac arrest after repeat coronary intervention on 8/01/16. He was discharged on 8/05/16. The patient has requested reimbursement for wearable cardioverter defibrillator. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of this patient. This patient presented with a cardiac arrest in the setting of acute myocardial infarction and then had recurrent ventricular tachycardia/cardiac arrest within the first 24 hours of infarction in the setting of recurrent ischemia. In this circumstance, ventricular tachycardia/fibrillation within the first 24 hours of acute myocardial infarction is generally not predictive of subsequent ventricular tachycardia/ventricular fibrillation. In addition, the patients ejection fraction was not reduced to 35% or less. The documentation does not support the medical need for immediate placement of a defibrillator (wearable or implantable). Placement of a prophylactic defibrillator is not recommended until a period of time greater than 90 days where continued left ventricular dysfunction (ejection fraction 35% or less) is documented to persist despite appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation. Thus, the wearable cardioverter defibrillator was not likely to have been more effective 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.
| 1 |
The parent of a 15-year-old male enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that the patient is a 15-year-old male with Crohns disease and perianal fistulas. On 3/02/16, he presented with epigastric pain, but no diarrhea or blood in the stool after two doses of Remicade. Prometheus Anser IFX testing was ordered to be performed prior to the next infusion. Per the 9/09/16 provider note, Remicade dose was increased based on the test results. The Health Insurer has denied reimbursement for Prometheus Anser IFX testing performed on 5/13/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient. In this case, Anser IFX was ordered to determine Remicade level and whether | Upheld | Experimental | Summary Reviewer 3
The parent of a 15-year-old male enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that the patient is a 15-year-old male with Crohns disease and perianal fistulas. On 3/02/16, he presented with epigastric pain, but no diarrhea or blood in the stool after two doses of Remicade. Prometheus Anser IFX testing was ordered to be performed prior to the next infusion. Per the 9/09/16 provider note, Remicade dose was increased based on the test results. The Health Insurer has denied reimbursement for Prometheus Anser IFX testing performed on 5/13/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient. In this case, Anser IFX was ordered to determine Remicade level and whether antibodies to infliximab were present. The use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear Remicade levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing. Based on clinical literature, Prometheus Anser IFX testing performed on 5/13/16 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.
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A 63-year-old male enrollee has requested authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has been diagnosed with acute obstructive sleep apnea. The physician reviewer found that the patient is a 63-year-old male who has a history of snoring and obstructive sleep apnea (OSA). An initial baseline polysomnogram, performed in December 2013, confirmed moderate to severe OSA with an apnea hypopnea index (AHI) of 56.5 episodes per hour sleep. Oxygen saturation nadir was 87 percent. A follow-up titration study was performed confirming that bilevel positive airway pressure (BPAP) of 18 and expiratory positive airway pressure (EPAP) of 13 showed improvement of the patients symptoms, but the patient has become intolerant to the continuous positive airway pressure (CPAP) therapy. The submitted medical records document that the patient underwent procedures to improve symptoms of sleep disordered breathing including nasal surgery, septoplasty and inferior turbinate reduction.
the sleep parameters. Drug-induced sleep endoscopy was performed on 7/1/15 under anesthesia. The report confirmed evidence that the patient does have a severe caudal collapse in addition to severe lateral collapse of the retropharyngeal palate. On 8/5/15, the patient underwent further surgical intervention which included suspension expansion pharyngoplasty. This was performed to improve the patients symptoms of airway obstruction. Postoperative subjective evaluation confirmed that the patient had some degree of improved sleep quality without velopharyngeal insufficiency or dysphagia.
suggested upper airway stimulation to improve the patient's symptoms of OSA. The patient requests | Upheld | Experimental | Summary Reviewer 2
A 63-year-old male enrollee has requested authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has been diagnosed with acute obstructive sleep apnea. The physician reviewer found that the patient is a 63-year-old male who has a history of snoring and obstructive sleep apnea (OSA). An initial baseline polysomnogram, performed in December 2013, confirmed moderate to severe OSA with an apnea hypopnea index (AHI) of 56.5 episodes per hour sleep. Oxygen saturation nadir was 87 percent. A follow-up titration study was performed confirming that bilevel positive airway pressure (BPAP) of 18 and expiratory positive airway pressure (EPAP) of 13 showed improvement of the patients symptoms, but the patient has become intolerant to the continuous positive airway pressure (CPAP) therapy. The submitted medical records document that the patient underwent procedures to improve symptoms of sleep disordered breathing including nasal surgery, septoplasty and inferior turbinate reduction. The surgical interventions improved and eliminated the majority of the patient's symptoms of snoring but did not improve all the sleep parameters. Drug-induced sleep endoscopy was performed on 7/1/15 under anesthesia. The report confirmed evidence that the patient does have a severe caudal collapse in addition to severe lateral collapse of the retropharyngeal palate. On 8/5/15, the patient underwent further surgical intervention which included suspension expansion pharyngoplasty. This was performed to improve the patients symptoms of airway obstruction. Postoperative subjective evaluation confirmed that the patient had some degree of improved sleep quality without velopharyngeal insufficiency or dysphagia. There is a report of a home sleep study performed following these interventions on 11/24/15 confirming that the AHI was at 34.5 episodes per hour of sleep and that the oxygen saturation nadir was 85%. The provider suggested upper airway stimulation to improve the patient's symptoms of OSA. The patient requests authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer denied this request as investigational for treatment of this patients medical condition. In this patients case, the requested services are not likely to be more effective than other forms of therapy for treatment of his OSA. The medical studies support implantation of cranial nerve stimulator in select patients. To be considered for surgical implantation of a cranial nerve stimulator, patients must have previously failed prior surgical management including uvulopalatopharyngoplasty, nasal reconstruction and other techniques in addition to therapy and failure with CPAP and mandibular advancement prostheses. Patients who are candidates for upper airway stimulation therapy must have undergone appropriate evaluations with polysomnogram, having reduced body mass index (BMI) of less than 32, along with objective upper airway evaluation measures documenting narrowing of the retro-palatal airway (Doghramji and Boon). The patient in this case, does not meet those criteria. The patients BMI is greater than 32. Moreover, there was no indication demonstrating that the patient has sustained any weight loss with prior medical management to reduce the BMI score below 32. Additionally, the drug-induced sleep endoscopy confirmed evidence of a very severe collapse which may be concentric. As such, implantation of cranial nerve stimulator is not likely to be more effective than other standard modalities available 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.
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A 63-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene test
(CPT 81529) performed on 5/27/21. The Health Insurer has denied this request and reported that
the services at issue were investigational for the evaluation of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 2
A 63-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene test
(CPT 81529) performed on 5/27/21. The Health Insurer has denied this request and reported that
the services at issue were investigational for the evaluation of the enrollees medical condition.
The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages.
Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph
nodes for those with a high depth of invasion, from 0.76 mm to 1.0 mm. Metastases to regional
lymph nodes may be amenable to excision but suggest a high risk for the development of
metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.
While Gerami and colleagues report that GEP signature accurately predicted metastasis risk in a
multicenter cohort of primary cutaneous melanoma tumors, the patients analyzed were part of
a high-risk cohort, and there appears to be some lack of consistency between various genes being
used as biomarkers. The use of data from DecisionDx-Melanoma is not part of routine analysis
following SLNB. The service at issue is novel, and it unclear how its results would be incorporated
it into the treatment algorithm beyond standard staging techniques recommended by the
National Comprehensive Cancer Network (NCCN). Therefore, the DecisionDx-Melanoma gene
test (CPT 81529) performed on 5/27/21 was not likely to have been more beneficial for
evaluation of the patients condition than any available standard therapy.
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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. | Upheld | Experimental | Summary Reviewer 2
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 overall, the routine inclusion of HPV screening in women under age 30 does not provide additional benefit over cytology and increases the risk of unnecessary interventions. This patient was under age 30. The guidelines from the American Cancer Society (ACS) and the American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology (ASCP) all recommend delaying co-testing until after age 30. Thus, there is a lack of documentation supporting an indication for the HPV testing performed on 8/26/16, and the testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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The parent of an eight-year-old male enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. The Health Insurer has denied this request indicating that the requested therapy is not medically for treatment of the enrollees behavioral health conditions.
the patient has not been evaluated for autism by a developmental and | Upheld | Medical Necessity | Summary Reviewer
The parent of an eight-year-old male enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. The Health Insurer has denied this request indicating that the requested therapy is not medically for treatment of the enrollees behavioral health conditions. The physician reviewer found that in this clinical setting, ABA therapy is not medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, a diagnosis of autism has not been established. In addition, there is a lack of peer-reviewed literature supporting ABA therapy for the treatment of generalized anxiety disorder, developmental coordination disorder or adjustment reaction. There is also a lack of research supporting ABA for treatment of behavioral regulation or self-control outside of a diagnosis of autism spectrum disorder. The standard of care for treating generalized anxiety disorder include medications and counseling (Dobson and Strawn; Mohatt, et al). Moreover, the patient has not been evaluated for autism by a developmental and behavioral pediatrician utilizing Autism Diagnostic Observation Schedule (ADOS) and Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic criteria. Therefore, ABA therapy has not been established as medically necessary for treatment of the patients medical condition. Therefore, the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
A 54-year-old female enrollee has requested reimbursement for color-flow Doppler echocardiography performed on 3/29/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees chest pain and dyspnea.
this patient had risk factors for coronary heart disease and symptoms of both chest pain and dyspnea. She was referred for color-flow Doppler echocardiography. Given her symptoms of chest pain and dyspnea, | Overturned | Experimental | Summary Reviewer 1
A 54-year-old female enrollee has requested reimbursement for color-flow Doppler echocardiography performed on 3/29/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees chest pain and dyspnea. The physician reviewer found that this patient had risk factors for coronary heart disease and symptoms of both chest pain and dyspnea. She was referred for color-flow Doppler echocardiography. Given her symptoms of chest pain and dyspnea, along with the fact that this was the first and only investigation of these complaints, assessment of her cardiac valves and pulmonary pressures was reasonable, indicated and appropriate in order to rule out both ischemic and valvular heart disease as an etiology of her chest pain and dyspnea symptoms. Therefore, color-flow Doppler echocardiography performed on 3/29/18 was likely to have been more efficacious than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| 1 |
A 61-year-old male enrollee has requested authorization and coverage for intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures). The Health Insurer indicates that the requested services are investigational for the treatment of the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the requested services. | Upheld | Experimental | Summary Reviewer 1
A 61-year-old male enrollee has requested authorization and coverage for intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures). The Health Insurer indicates that the requested services are investigational for the treatment of the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the requested services. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This is a spinal deformity operation plus placement of pedicle screws. Intraoperative monitoring is needed to monitor the L5 nerve root during reduction and correction of spondylolisthesis to minimize foot drop and permanent palsy. Additionally, the requested services will allow the provider to monitor for any breach of pedicle screws. Given how long the surgery will take in prone position, the requested services can also allow the provider to monitor the upper extremity to make sure the patient does not end up with a brachial plexus and/or ulnar nerve palsy. Therefore, intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures) is likely to be more beneficial than any available standard therapy.
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A 55-year-old female enrollee has requested authorization and coverage for tremfya 100 mg/mL syringe. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition.
In this case, the patient has severe psoriasis with involvement of the scalp, foot and hands over 15% body surface area. The patient has tried and failed topical steroids, oral steroids, cyclosporine A, and Taltz | Overturned | Medical Necessity | Summary Reviewer
A 55-year-old female enrollee has requested authorization and coverage for tremfya 100 mg/mL syringe. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The American College of Rheumatology/National Psoriasis Foundation published updated guidelines in 2019. Severe psoriasis is defined as disease affecting greater than 5 to 10% body surface area or disease affecting the face, palms or soles of feet. The National Psoriasis Foundation considers Tremfya a first-line therapy when ultraviolet B therapy is not available. The American Academy of Dermatology and the National Psoriasis Foundation issued a joint position statement in April 2019. Currently, there are 11 biologic agents on the market or in clinical trials for the treatment of psoriasis. Tremfya was approved by the U.S. Food and Food Drug Administration in July 2017 for use in psoriasis. Tremfya is recommended as a monotherapy treatment option in adult patients with scalp, nail, and plaque-type palmoplantar psoriasis. In this case, the patient has severe psoriasis with involvement of the scalp, foot and hands over 15% body surface area. The patient has tried and failed topical steroids, oral steroids, cyclosporine A, and Taltz (not tolerated). Given the scenario of failure of standard therapies for severe psoriasis, it is reasonable to consider a trial of biologics. The requested medication is medically appropriate in this clinical setting. Therefore, Tremfya 100 mg/mL syringe is medically necessary for the treatment of this patient. | 1 |
The patient is a 59-year-old female with a malignant melanoma of the left lateral chest. Pathology showed Breslow thickness of 1.28 mm, Clark level IV. The margins of excision were free of melanoma. Molecular profiling with DecisionDx-Melanoma testing was performed on 5/12/16. The patient has requested reimbursement for gene testing performed on 5/12/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. This patient had an early stage melanoma. | Upheld | Experimental | Summary Reviewer 3
The patient is a 59-year-old female with a malignant melanoma of the left lateral chest. Pathology showed Breslow thickness of 1.28 mm, Clark level IV. The margins of excision were free of melanoma. Molecular profiling with DecisionDx-Melanoma testing was performed on 5/12/16. The patient has requested reimbursement for gene testing performed on 5/12/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. This patient had an early stage melanoma. The National Comprehensive Cancer Network guideline states while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of this testing are not likely to alter treatment and surveillance recommendations. Thus, gene testing performed on 5/12/16 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 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, MRI showed nonspecific atrophy. The EEG showed spike and slow wave discharges suggesting epilepsy. In addition, neuropsychology testing suggested frontotemporal dementia, and the examination showed Parkinsonian features. The patient presented with a subacute onset of progressive memory problems. | Overturned | Experimental | Summary Reviewer 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. The physician reviewer found that 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. PET is a standard procedure performed by providers when dementia is atypical, and most specifically to differentiate Alzheimers disease from frontotemporal dementia. This diagnostic procedure allows the patient and his family to better understand prognosis and treatment, and guide the treating provider to provide the best treatment. In this case, MRI showed nonspecific atrophy. The EEG showed spike and slow wave discharges suggesting epilepsy. In addition, neuropsychology testing suggested frontotemporal dementia, and the examination showed Parkinsonian features. The patient presented with a subacute onset of progressive memory problems. In this complex clinical setting, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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 |
A 57-year-old female enrollee has requested reimbursement for the DecisionDx-Melanoma Assay provided on 7/20/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma.
The records document melanoma of 1.02 mm Breslow depth on the left labia. | Upheld | Experimental | Summary Reviewer 3
A 57-year-old female enrollee has requested reimbursement for the DecisionDx-Melanoma Assay provided on 7/20/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the medical evidence does not support the superior efficacy of the services at issue in this patients case. The records document melanoma of 1.02 mm Breslow depth on the left labia. 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 this type of testing is not considered to be standard of care in this clinical setting. DecisionDx-Melanoma Assay is not expected to impact the treatment or outcome of the patients melanoma. Thus, DecisionDx-Melanoma Assay performed on 7/20/18 was not likely to have been more efficacious than other methods of evaluating this patient.
| 1 |
A 28-year-old female insured has requested authorization and coverage for intravenous (IV)
Gammagard. The Health Insurer has denied this request indicating that the requested treatment is
considered investigational for the treatment of the insured's refractory relapsing polychondritis.
In this case, the patient
presents with relapsing polychondritis. The records provided for review indicate that the patient
has tried and failed treatment with multiple therapies from several classes of medications. The
provider has recommended a continuation of IVI | Overturned | Experimental | Summary Reviewer 3
A 28-year-old female insured has requested authorization and coverage for intravenous (IV)
Gammagard. The Health Insurer has denied this request indicating that the requested treatment is
considered investigational for the treatment of the insured's refractory relapsing polychondritis.
The physician reviewer found that there is limited medical literature studying IVIG as a treatment
option for patients with relapsing polychondritis. Relapsing polychondritis is a rare autoimmune
disorder, and official guidelines to utilize certain therapies are not likely to be available in the near
future. However, for patients who have tried and failed treatment with multiple therapies from
several classes of medications, IVIG is appropriate as the next-line treatment option. This is
particularly applicable when its efficacy has been established for a particular patient in keeping
the disease stable or in remission. According to one study by Lekpa and Chevalier, IVIG has been
shown to be effective in some patients with relapsing polychondritis. In this case, the patient
presents with relapsing polychondritis. The records provided for review indicate that the patient
has tried and failed treatment with multiple therapies from several classes of medications. The
provider has recommended a continuation of IVIG therapy which has already been shown to be
the most effective treatment option for this patient. All told, the requested IV Gammagard is likely
to be more beneficial for the treatment of the patients condition than any available standard
therapy.
| 1 |
A 51-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/15/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. | Upheld | Experimental | Summary Reviewer 2
A 51-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/15/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the Anser IFX Test is a quantitative measurement of serum infliximab and anti-infliximab antibodies. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there is a lack of well-controlled clinical trials to confirm that use of the Anser IFX test leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. In addition, there are technical factors relating to the use of different assay methods across studies. It has not yet been established whether the use of threshold levels aids in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. In sum, Anser IFX testing performed on 4/15/14 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 55-year-old female enrollee has requested authorization and coverage for arthrodesis of sacroiliac (SI) joint (27279). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees SI joint pain. | Upheld | Experimental | Summary Reviewer 3
A 55-year-old female enrollee has requested authorization and coverage for arthrodesis of sacroiliac (SI) joint (27279). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees SI joint pain. The physician reviewer found the request for arthrodesis of SI joint (27279) is not likely to be beneficial for this patient. The reliance of steroid local injection into the SI joint as an indicator for identification of a specific pain generator is not sufficient to localize pain generation from the SI joint in the face of multifactorial chronic pain. Local anesthetic injection is questionable since the SI joint is large and irregular and only acceptable to needle intervention in portions of the joint. In sum, it is not likely to be beneficial for this patient to undergo SI instrumentation and fusion as a treatment method for her condition of chronic pain. 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 50-year-old female enrollee has requested authorization and coverage for the prescription drug Aubagio. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees multiple sclerosis. | Overturned | Medical Necessity | Summary Reviewer
A 50-year-old female enrollee has requested authorization and coverage for the prescription drug Aubagio. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees multiple sclerosis. The physician reviewer found that Aubagio is one of three oral therapies now available to treat relapsing forms of multiple sclerosis. Aubagio is a standard therapy for multiple sclerosis. There is a lack of data indicating that the required next step of using Rebif is medically a more sound decision. There is a lack of head-to-head data showing Rebif to be more efficacious or safe than Aubagio. Clinical experience shows that Aubagio as an oral agent does not cause injection site reactions or flu-like symptoms. All told, Aubagio is medically indicated 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.
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A 61-year-old male enrollee has requested authorization and coverage for Tykerb. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition.
that this patient has a salivary gland cancer, which is a rare tumor that has
. This patient was treated with paclitaxel and trastuzumab along with directed stereotactic radiotherapy of the brain metastases. The records documented disease progression, and his provider is attempting to | Overturned | Experimental | Summary Reviewer 3
A 61-year-old male enrollee has requested authorization and coverage for Tykerb. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient has a salivary gland cancer, which is a rare tumor that has a high propensity for distant metastases. Stage IV disease, as in this case, is very difficult to treat because it is poorly responsive to conventional chemotherapy regimens. Since the tumor is rare, large randomized clinical trial evidence cannot be expected. Patients with refractory or relapsed cancer who have exhausted standard treatments are usually considered for clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues performed a study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This patient was treated with paclitaxel and trastuzumab along with directed stereotactic radiotherapy of the brain metastases. The records documented disease progression, and his provider is attempting to target the HER2 amplification by lapatinib. There is phase II data demonstrating that this drug may induce stable disease in patients with salivary gland cancers. It also penetrates the blood-brain barrier and may be more effective than trastuzumab. Thus, Tykerb is likely to be more effective than other available treatment options.
| 1 |
patient is a 36-year-old female with a history of class 3 obesity complicated by prediabetes and
dyslipidemia. The records available for review indicate that the patient had a body mass index (BMI)
over 40 kg/m2 in September 2021.
, the patient has a history of class 3
obesity complicated by prediabetes and dyslipidemia. The records reflect that the patient has attempted
treatment with diet management and exercise without significant benefit. The patient has also tried and
failed treatment with medications such as phentermine. | Overturned | Medical Necessity | Summary
The patient is a 36-year-old female with a history of class 3 obesity complicated by prediabetes and
dyslipidemia. The records available for review indicate that the patient had a body mass index (BMI)
over 40 kg/m2 in September 2021. The physician reviewer found that at issue is whether the requested
Wegovy is medically necessary for the treatment of this patient. According to Gadde and colleagues,
while lifestyle modification is recommended as the cornerstone of obesity management, many patients
do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and
neurohormonal adaptation of the body in response to weight loss. There are multiple pharmacologic
therapies available for weight management. Wegovy is a member of a class of medications known as
glucagon-like peptide 1 (GLP-1) analogs. As noted in the medical literature, GLP-1 analogs have been
shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudsen and
Lau). Studies have demonstrated Wegovys ability to promote weight loss via reduced appetite and
energy intake and delayed gastric emptying (Cornell). In this case, the patient has a history of class 3
obesity complicated by prediabetes and dyslipidemia. The records reflect that the patient has attempted
treatment with diet management and exercise without significant benefit. The patient has also tried and
failed treatment with medications such as phentermine. Overall, Wegovy has been shown to effectively
promote weight loss for patients in conjunction with diet and exercise. Therefore, the requested
Wegovy is medically necessary for the treatment of this patient. | 1 |
A 20-year-old female enrollee has requested reimbursement for residential treatment center (RTC) services provided from 5/15/16 through 5/17/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder.
. The patient was above her ideal body weight, was not suicidal or psychotic, and had normal laboratory data. | Upheld | Medical Necessity | Summary Reviewer
A 20-year-old female enrollee has requested reimbursement for residential treatment center (RTC) services provided from 5/15/16 through 5/17/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder. The physician reviewer found the records provided for review indicate this patient was not in need of 24-hour per day monitoring and supervision. In addition, she was not likely to require inpatient hospital admission if discharged from RTC level of care. The patient was above her ideal body weight, was not suicidal or psychotic, and had normal laboratory data. The patients depression could have been safely and adequately managed at a lower level of care. The patients needs could have been safely and adequately managed in a less restrictive treatment setting as well. All told, the RTC services provided from 5/15/16 through 5/17/16 were not medically necessary for treatment of this patients medical condition. 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 57-year-old female enrollee has requested authorization and coverage for endovenous ablation therapy of incompetent vein. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees chronic venous insufficiency.
the patient is doing well and is without complaints or concerns and is using compression stockings | Upheld | Medical Necessity | Summary Reviewer
A 57-year-old female enrollee has requested authorization and coverage for endovenous ablation therapy of incompetent vein. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees chronic venous insufficiency. The physician reviewer found that the documentation does not support the medical necessity of the requested endovenous ablation therapy of incompetent veins for treatment of this patients varicosities. The most recent evaluation documents that the patient is doing well and is without complaints or concerns and is using compression stockings as prescribed. Therefore, there is no indication for additional treatments. Accordingly, the requested endovenous ablation therapy of incompetent vein is not supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | 1 |
A 65-year-old female enrollee has requested reimbursement for collagen crosslink testing and homocysteine testing provided on 12/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. | Overturned | Experimental | Summary Reviewer 1
A 65-year-old female enrollee has requested reimbursement for collagen crosslink testing and homocysteine testing provided on 12/03/18. 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 osteoporosis is a condition of thinning of the bones that leads to increased risk of fracture. It is defined by the World Health Organization as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass as measured by dual-energy x-ray absorptiometry (DEXA). Bone mineral density (BMD) assessment, via DEXA, is still the criterion standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. Evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. The medical evidence supports collagen crosslink testing in this clinical setting. However, there is a lack of support for homocysteine testing in this patients case. Ohishi and colleagues found that serum total homocysteine levels had no correlation with bone mineral density. While some studies have suggested that there may be an association between homocysteine levels and bone loss, to date, the association between homocysteine imbalance and its role in bone loss remains unclear. Enneman and colleagues noted plasma levels of homocysteine were significantly inversely associated with both bone ultrasound parameters and with bone mineral density. However, the size of the associations seems to be of limited clinical relevance and may, therefore, not explain the previously observed association between plasma homocysteine and osteoporotic fracture incidence. In sum, collagen crosslink testing provided on 12/03/18 was likely to have been more beneficial than other available methods of evaluating this patient. However, the superior effectiveness of homocysteine testing has not been established.
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An 18-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 6/23/17 through 7/16/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.
The patient has an extensive psychiatric history involving multiple prior inpatient treatment programs. The patient had a serious suicide attempt on 5/26/17 with Ativan and Vodka, which can be a lethal combination. The patient has a history of self-harm and is impulsive. She was ambivalent about treatment goals. It appears that the patient decompensated in less restrictive settings. There
for the services at issue in this clinical setting. The records indicate that the patient had failed less restrictive means for treatment. | Overturned | Medical Necessity | Summary Reviewer
An 18-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 6/23/17 through 7/16/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that submitted documentation supports the medical necessity of the services at issue. The patient has an extensive psychiatric history involving multiple prior inpatient treatment programs. The patient had a serious suicide attempt on 5/26/17 with Ativan and Vodka, which can be a lethal combination. The patient has a history of self-harm and is impulsive. She was ambivalent about treatment goals. It appears that the patient decompensated in less restrictive settings. There is sufficient support for the services at issue in this clinical setting. The records indicate that the patient had failed less restrictive means for treatment. Thus, mental health residential treatment provided from 6/23/17 through 7/16/17 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 61-year-old male enrollee has requested reimbursement for proton beam radiation therapy provided from 6/26/19 through 8/29/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. | Upheld | Medical Necessity | Summary Reviewer
A 61-year-old male enrollee has requested reimbursement for proton beam radiation therapy provided from 6/26/19 through 8/29/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that currently, there is a lack of clinical data in the medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for tumors of the head and neck area. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT). A comparative analysis by Sio and colleagues found no significant difference in symptom burden in the acute and chronic phases of treatment with proton therapy compared to photon therapy for head and neck cancer. The American Society of Radiation Oncology (ASTRO) emerging technology committee report on proton therapy specifically states that there is insufficient data to recommend proton beam therapy for routine head and neck radiation therapy outside of clinical trials. The comparative plan was reviewed in detail and shows that standard treatment methods are sufficient to treat this patient and that the proton therapy plan does not result in a meaningful clinical difference despite having lower dose to one of the parotid glands. Consensus group guidelines do not support the use of proton therapy in this setting. There is a lack of level I evidence to support the use of proton therapy for the treatment of head and neck cancer. Therefore, proton beam radiation therapy provided from 6/26/19 through 8/29/19 was not medically necessary for the treatment of this patient. | 0 |
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. | Upheld | Experimental | Summary Reviewer 3
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 testing for thrombophilias after early miscarriage has not been shown to be clinically useful in the low risk population. Finding a genetic mutation in this population for MTHFR, Factor V (Leiden) or prothrombin genes would not change the clinical management of the patient currently or with a new pregnancy. Testing for these mutations has only been found to be clinically useful in a patient who has a personal history of a venous thrombotic event or a first-degree relative with gene mutation who has had a venous thrombotic event. In this case, the literature does not support testing for these mutations because there would be no change in clinical management. All told, 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.
| 0 |
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. | Overturned | Experimental | Summary Reviewer 3
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 Polly and colleagues performed a randomized controlled trial of minimally invasive sacroiliac joint fusion using triangular titanium implants was compared to nonsurgical treatment at 12 months. A total of 148 patients with sacroiliac joint dysfunction were randomly assigned to minimally invasive sacroiliac joint fusion with triangular titanium implants or nonsurgical treatment. The study showed that minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction caused by degenerative sacroiliitis or sacroiliac joint disruptions. Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. In addition, Whang and colleagues compared sacroiliac joint fusion using triangular titanium implants to nonsurgical management. The conclusions were that at six-month follow-up the minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction due to degenerative sacroiliitis or sacroiliac joint disruptions. In this case, physical examination and multiple diagnostic sacroiliac injections have identified the pain generator. Therefore, evidence of neural compression on the imaging studies is not relevant. Based upon a review of the recent literature, the requested minimally invasive sacroiliac joint fusion has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested 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 47-year-old male enrollee has requested reimbursement for automated evacuation of meibomian glands performed on 2/2/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees meibomian gland dysfunction. | Upheld | Experimental | Summary Reviewer 1
A 47-year-old male enrollee has requested reimbursement for automated evacuation of meibomian glands performed on 2/2/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees meibomian gland dysfunction. The physician reviewer found that the automated evacuation of meibomian glands performed on 2/2/15 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This procedure utilizes a device that heats the palpebral surface of upper and lower eyelids while simultaneously applying graded pulsatile pressure to the outer eyelid for 12?minutes, thereby expressing the meibomian glands during heating (Friedland, et al). The study results by Finis and colleagues showed that a single thermodynamic treatment is effective in the treatment of meibomian gland dysfunction and that the effects last for at least six months. Although automated evacuation of meibomian glands have promise, there is a lack of evidence in the medical literature supporting that the services at issue were more effective than standard therapy such as hot compresses and lid hygiene. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 61-year-old female enrollee has requested authorization and coverage for Hizentra. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees nonfamilial hypogammaglobulinemia.
the patient has been vaccinated with pneumococcal vaccines with pre and post vaccinations titer, | Upheld | Medical Necessity | Summary Reviewer
A 61-year-old female enrollee has requested authorization and coverage for Hizentra. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees nonfamilial hypogammaglobulinemia. The physician reviewer found that although the records indicate that the patient presents with recurrent infections, there is a lack of supporting documentation, such as chest x-rays, computed tomography of the sinuses or antibiotic logs, to confirm recurrent infections. In addition, the record does not demonstrate that the patient has been vaccinated with pneumococcal vaccines with pre and post vaccinations titer, which is evidence of persistent hypogammaglobulinemia. There is also no documentation that the patient has trialed prophylactic antibiotics or other therapies such as aggressive allergic rhinitis treatment, vaccination with conjugate pneumococcal vaccine or a trial of prophylactic antibiotics. The diagnosis of common variable immune deficiency (CVID) requires significantly reduced total serum concentrations of immunoglobulin, low immunoglobulin A (IgA) and/or immunoglobulin M (IgM), poor or absent response to immunization and exclusion of other immunodeficiency states or causes. In this case, the patient is reported to have low total IgG, but none of the other criteria of CVID (Chapel et al; Chapel and Cunningham-Rundles). Other causes of hypogammaglobulinemia have not been evaluated to include gastrointestinal or urinary loss of protein. Furthermore, the treatment of hypogammaglobulinemia with replacement immunoglobulin remains controversial. Most experts recommend treatment which includes immunization with conjugated pneumococcal vaccine (Prevnar 7 or 13), aggressive treatment of other conditions predisposing to recurrent sinopulmonary infections, increased vigilance and appropriate antibiotic therapy for infections, prophylactic antibiotics and intravenous immunoglobulin/subcutaneous immunoglobulin (IVIG/SCIG). In this case, the patients immune system has not been fully evaluated, there has not been aggressive treatment of her possible comorbid conditions. The documentation does not support that IVIG is safe and effective in this clinical setting. In sum, the documentation submitted for review fails to demonstrate a primary immunodeficiency related to antibody deficiency. Although there is evidence of hypogammaglobulinemia, the records lack a full evaluation of the patients immune system. As such, the request for Hizentra is not medically necessary for treatment of the patients medical condition. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
The patient is a 44-year-old male with a history of morbid obesity and hypercholesterolemia. The patient has requested authorization and coverage for Saxenda. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. | Upheld | Medical Necessity | Summary Reviewer
The patient is a 44-year-old male with a history of morbid obesity and hypercholesterolemia. The patient has requested authorization and coverage for Saxenda. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that according to the U.S. Food and Drug Administration (FDA), Saxenda is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (eg, hypertension, type 2 diabetes mellitus, dyslipidemia). The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention: a combination of diet, exercise, and behavioral modification. All patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with a body mass index greater than 30 kg/m2 or a BMI of 27 through 29.9 kg/m2 with comorbidities, such as hypertension or diabetes mellitus, has failed to achieve weight loss goals through diet and exercise alone, pharmacologic therapy is suggested. In this case, limited documentation was provided despite requests. The submitted records do not document that the patient has failed treatment with counseling, calorie restriction and increased physical activity to achieve weight loss goals. Therefore, Saxenda is not medically necessary for the treatment of this patient. | 1 |
A 43-year-old female enrollee has requested reimbursement for services (HCPCS codes L0637, L0456 and L3030) provided on 3/2/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees back pain.
that this patient received a lumbar brace on 3/02/18, foot orthotics on 3/13/18, and thoracic brace on 3/20/18. In this case, the progress notes on 3/02/18 indicated that the patient already achieved 20 to 25% improvement in her low back pain. She was given a back brace without explanation of medical necessity. On 3/20/18, the patient reported a 50 to 55% improvement in her mid-back pain, and the records do not demonstrate the need for a thoracic supporting brace.
The treatment note dated 3/13/18 indicated that the patients back and hip condition had improved approximately 40 to 45%, and the patient received a pair of foot orthotics. | Upheld | Medical Necessity | Summary Reviewer
A 43-year-old female enrollee has requested reimbursement for services (HCPCS codes L0637, L0456 and L3030) provided on 3/2/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees back pain. The physician reviewer found that this patient received a lumbar brace on 3/02/18, foot orthotics on 3/13/18, and thoracic brace on 3/20/18. In this case, the progress notes on 3/02/18 indicated that the patient already achieved 20 to 25% improvement in her low back pain. She was given a back brace without explanation of medical necessity. On 3/20/18, the patient reported a 50 to 55% improvement in her mid-back pain, and the records do not demonstrate the need for a thoracic supporting brace. Back support has not been found to reduce lower back pain or help prevent lower back pain in this setting. The treatment note dated 3/13/18 indicated that the patients back and hip condition had improved approximately 40 to 45%, and the patient received a pair of foot orthotics. There is no documentation of foot symptoms or gait dysfunction warranting foot orthotics. Therefore, HCPCS codes L0637, L0456 and L3030 provided on 3/02/18, 3/13/18 and 3/20/18 were not medically necessary for the treatment of this patient. | 1 |
A 56-year-old male enrollee has requested reimbursement for des-gamma-carboxy prothrombin (DCP) testing performed on the enrollee on 5/29/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition.
-11.6 years). All patients had been identified as having HCC during screening, which included 12 patients assessed by ultrasound, four patients assessed with computerized tomography, two patients that underwent serum des-?-carboxy prothrombin testing and one patient that underwent serum a-fetoprotein testing. | Upheld | Experimental | Summary Reviewer 1
A 56-year-old male enrollee has requested reimbursement for des-gamma-carboxy prothrombin (DCP) testing performed on the enrollee on 5/29/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that non-alcoholic steatohepatitis (NASH) can progress to hepatocellular carcinoma (HCC) (Yasui, et al). Yasui and colleagues performed a study to examine the clinical and pathological course of how NASH progresses to HCC. The authors found that NASH progressed to HCC after a median follow-up period of 3.8 years (range: 0.5-11.6 years). All patients had been identified as having HCC during screening, which included 12 patients assessed by ultrasound, four patients assessed with computerized tomography, two patients that underwent serum des-?-carboxy prothrombin testing and one patient that underwent serum a-fetoprotein testing. In addition, the meta-analysis by Bertino and colleagues resulted in the following conclusion A search of the literature was made using cancer literature and the PubMed database for the following keywords: markers and HCC, a-fetoprotein (AFP) and HCC, Des-?-carboxy prothrombin (DCP) and HCC, squamous cell carcinoma antigen-immunoglobulin M complexes (SCCA-IgM Cs). Despite the large number of studies devoted to the immunohistochemistry of HCC, at the present time, the absolute positive and negative markers for HCC are still lacking, and even those characterized by very high sensitivity and specificity do not have a universal diagnostic usefulness. In conclusion none of the three biomarkers (AFP, DCP, SCCA-IgM Cs) is optimal. Currently the recommended screening strategy for patients with cirrhosis includes the determination of serum AFP levels and an abdominal ultrasound every six months to detect HCC at an earlier stage. Given the above, the DCP testing performed on 5/29/15 has not been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| 1 |
patient is a 48-year-old female with a history of episodic migraine headaches with associated
nausea, severe weakness, and ataxia. The provider has recommended continued treatment with
Qulipta. The Health Insurer has denied the requested treatment as not medically necessary for the
treatment of the patients medical condition.
the patient has a history of episodic migraines and has tried and
failed multiple acute | Overturned | Medical Necessity | Summary
The patient is a 48-year-old female with a history of episodic migraine headaches with associated
nausea, severe weakness, and ataxia. The provider has recommended continued treatment with
Qulipta. The Health Insurer has denied the requested treatment as not medically necessary for the
treatment of the patients medical condition. This denial is the subject of this appeal and
determination. The physician reviewer found that Qulipta is in class of drugs called gepants,
developed for the preventive treatment of episodic migraines in adult patients. Gepants play a
crucial role in migraine pathophysiology and are now established for preventive and acute
treatments (Edvinsson, et al.). Gepants demonstrated efficacy and tolerability in the preventive
treatment of migraines and are effective at reducing monthly migraine days (Ailani, et al.).
According to the American Headache Society (AHS) consensus statement, patients with migraines
should be considered for preventive treatment when attacks significantly interfere with patients
daily routines despite acute treatment, attacks are frequent, and there is failure or overuse of acute
treatments. The AHS further states that gepants should be personalized according to the needs of
individual patients. In this case, the patient has a history of episodic migraines and has tried and
failed multiple acute treatments, which fulfills the AHS criteria for preventative treatment. The
AHS recommends that treatment plans involving the preventive use of gepants be personalized
according to the needs of individual patients. For these reasons, the requested Qulipta 60 mg tablet
is medically necessary for the treatment of this patient.
| 1 |
A 61-year-old female enrollee has requested reimbursement for the in-office surgical injections performed on 8/4/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees lumbar spondylosis with arthropathy. | Upheld | Experimental | Summary Reviewer 1
A 61-year-old female enrollee has requested reimbursement for the in-office surgical injections performed on 8/4/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees lumbar spondylosis with arthropathy. The physician reviewer found that lumbar medial branch blocks are not investigational and are standard of care for lumbar facet mediated pain. Lumbar facet blocks are indicated for DDD and facet mediated pain in the axial lumbar spine. There are a multitude of studies indicating reduced pain, improved function and better quality of life following these injections. All told, the in-office surgical injections performed on 8/4/15 were likely to have provided this patient with an improved health outcome as compared to standard available therapies. 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 parent of a 15-year-old male enrollee has requested reimbursement for residential substance use disorders treatment provided from 8/21/18 through 9/03/18. 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 medical records indicate that the patient was not actively or passively suicidal. There were no reports of self-harm, and his risk of suicide was continuously rated as none.
The patient had some issues with level of function due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment.
The patient was noted to have a safe and sober living situation.
the patient had good response to the five months in the residential treatment center as evidenced by stable mood, | Upheld | Medical Necessity | Summary Reviewer
The parent of a 15-year-old male enrollee has requested reimbursement for residential substance use disorders treatment provided from 8/21/18 through 9/03/18. 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 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. In terms of risk of harm, the records support a score of 1. The medical records indicate that the patient was not actively or passively suicidal. There were no reports of self-harm, and his risk of suicide was continuously rated as none. With regards to functional status, the records support a score of 2. The patient had some issues with level of function due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment. In terms of comorbidity, the records support a score of 1. The patient does not have a history of past medical issues. His last substance use was several months prior to the disputed timeframe. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was noted to have a safe and sober living situation. In terms of level of support of the recovery environment, the records support a score of 2. The patients family was involved in treatment. With regards to resiliency and treatment history, the records support a score of 3. It appears that the patient had good response to the five months in the residential treatment center as evidenced by stable mood, cooperation in therapy, sobriety and insight into his need for treatment. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient actively participated in therapy, and he was cooperative with consistent engagement. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with staff. Thus, the patient has a composite score of 15. This score correlates with outpatient services. Therefore, residential substance use disorders treatment provided from 8/21/18 through 9/03/18 was not medically necessary for the treatment of this patient. | 1 |
A 34-year-old female enrollee has requested authorization and coverage for Sovaldi and RibaPak. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees hepatitis C virus. | Overturned | Medical Necessity | Summary Reviewer
A 34-year-old female enrollee has requested authorization and coverage for Sovaldi and RibaPak. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) all patients with chronic HCV regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions. Per the AASLD/IDSA guidelines, non-cirrhotic genotype 2b patients should be treated with Sovaldi and ribavirin for 12 weeks. This is based on multiple randomized controlled trials and Sovaldi is U.S. Food and Drug Administration (FDA) approved for patients with chronic hepatitis C genotype 2 regardless of fibrosis stage (Zeuzem, et al; Lawitz, et al; Jacobson, et al). AASLD guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and RibaPak is supported as medically necessary for the treatment of this patients hepatitis C infection. For the reasons provided, the requested medications are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| 1 |
A 63-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene test
(CPT 81529) performed on 5/27/21. The Health Insurer has denied this request and reported that
the services at issue were investigational for the evaluation of the enrollees medical condition.
/30/21 reported stage
IA cutaneous melanoma arising in a junctional dysplastic nevus. | Upheld | Experimental | Summary Reviewer 3
A 63-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene test
(CPT 81529) performed on 5/27/21. 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 in this case, a pathology report dated 4/30/21 reported stage
IA cutaneous melanoma arising in a junctional dysplastic nevus. GEP testing is an evolving
modality and may assist in differentiating precancerous from malignant lesions. While some
studies show its efficacy in risk stratification in melanoma, it is unclear if GEP performs better
than standard methods such as histopathologic risk factors and SLNB. In this clinical setting, the
NCCN guidelines for cutaneous melanoma recommend only wide excision and do not
recommend GEP. Therefore, the DecisionDx-Melanoma gene test (CPT 81529) performed on
5/27/21 was not likely to have been more beneficial for evaluation of the patients condition than
any available standard therapy.
| 1 |
The parent of a seven-year-old female enrollee has requested authorization and coverage for
Xeljanz 5 mg tablet. The Health Insurer has denied this request and reported that the requested
medication is investigational for the treatment of the enrollees alopecia.
In this case, the patient has extensive alopecia
areata. Given that this patient has tried and failed multiple therapies | Overturned | Experimental | Summary Reviewer 2
The parent of a seven-year-old female enrollee has requested authorization and coverage for
Xeljanz 5 mg tablet. The Health Insurer has denied this request and reported that the requested
medication is investigational for the treatment of the enrollees alopecia. The physician reviewer
found that there is a large body of growing evidence that JAK inhibitors, including tofacitinib, are
efficacious and safe for the treatment of alopecia areata. The FDA recently approved the use of
Olumiant, a JAK inhibitor, for the treatment of alopecia areata. Given this FDA approval, the use
of JAK inhibitors for the treatment of alopecia areata is considered standard therapy. Current
medical literature supports the improvement of alopecia treated with tofacitinib. Ibrahim and
colleagues report that oral tofacitinib is a successful treatment for alopecia areata. Liu and
colleagues conclude that tofacitinib should be considered for the treatment of severe alopecia
areata, alopecia totalis, and alopecia universalis. In this case, the patient has extensive alopecia
areata. Given that this patient has tried and failed multiple therapies including topical steroids,
minoxidil, and topical tofacitinib, and systemic prednisone, and has responded well to tofacitinib,
it is likely that Xeljanz will be more beneficial than any other standard treatment. Therefore,
Xeljanz 5 mg tablet is likely to be more beneficial for treatment of the patients condition than
any available standard therapy.
| 1 |
patient is a 69-year-old female who presented with an abnormal mammogram. This revealed a mass on the right side measuring 0.7 cm. | Overturned | Medical Necessity | Summary Reviewer
The patient is a 69-year-old female who presented with an abnormal mammogram. This revealed a mass on the right side measuring 0.7 cm. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this clinical setting. Current guidelines do endorse the use of intraoperative radiation therapy in the treatment of breast cancer. This patient would fall into the suitable group for the use of intraoperative radiation in patients with invasive ductal cancer. Phase 3 studies have shown equivalent outcomes in patients who undergo standard radiation therapy and intraoperative radiation therapy. The main benefit with intraoperative radiation therapy is that it can be done in a shorter course of time, and the patient does not require extra trips to a radiation oncology facility. Furthermore, treatment with intraoperative breast radiation treats only part of the breast, which may be associated with improved cosmesis. Therefore, intraoperative radiation therapy is medically necessary for the treatment of this patient.
| 1 |
A 27-year-old male enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and associated inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. | Upheld | Experimental | Summary Reviewer 1
A 27-year-old male enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and associated inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Skubleny and colleagues concluded, aLong-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation.a Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. Sheu and Rattner concluded, aThe long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined.a The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment. LINX has significant potential adverse effects and can be associated with poor outcomes. Therefore, LINX Reflux Management System (code 43284) and associated inpatient bed day is not likely to be more beneficial than other available standard therapy.
| 0 |
The patient is a 23-year-old female with no formal psychiatric history. The patient has requested reimbursement for inpatient hospitalization care from 4/13/21 through 4/21/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient.
. On presentation to the emergency department, the patient was very disorganized but did endorse suicidality. Additionally, the patient was paranoid, wandering outside the home, vigilant to possible threats and compromising her own safety with lack of awareness of the environment.
, the patient was repeatedly agitated on the inpatient unit,
medication. She was unable to tolerate social interactions or groups | Overturned | Medical Necessity | Summary Reviewer
The patient is a 23-year-old female with no formal psychiatric history. The patient has requested reimbursement for inpatient hospitalization care from 4/13/21 through 4/21/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient met the criteria for inpatient services provided from 4/13/21 through 4/21/21. Dimension 1 (risk of harm) assesses potential for harm to self or others. On presentation to the emergency department, the patient was very disorganized but did endorse suicidality. Additionally, the patient was paranoid, wandering outside the home, vigilant to possible threats and compromising her own safety with lack of awareness of the environment. The records support a score of 4 for this dimension. Dimension 2 (function) assesses the degree to which a person is able to fulfill social responsibilities, interact with, maintain physical functioning and capacity for self-care. In this case, the patient was repeatedly agitated on the inpatient unit, requiring medication. She was unable to tolerate social interactions or groups and neglected activities of daily living. The patient was unable to be managed at home without being monitored around the clock, even on discharge from the unit. Thus, the records support a score of 5 for this dimension. Dimension 3 (comorbidity) assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The patient had iron deficiency anemia and numerous abnormalities rheumatologically and neurologically that needed to be pursued through further testing and neuroimaging, although the patient was too paranoid to cooperate for an MRI. Thus, the records support a score of 4 for this dimension. Dimension 4A (recovery environment a stress) assesses the stressors in the environment, social circumstances, and interpersonal relationships. Prior to her admission, the patient perceived significant overwhelming demands in her job that she was unable to meet, prompting her to quit her job but then decompensating further. Thus, the records support a score of 4 for this dimension. Dimension 4B (recovery environment dimension a support) assesses the presence of family and social support to augment the recovery environment. Although the patientas parents are supportive, the patient was so ill that she was unable to access resources from her parents, and the parents were no longer able to keep her safe outside the hospital. Thus, the records support a score of 4 for this dimension. Dimension 5 (treatment and recovery history) assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. Despite full and adequate trial of Risperdal in the hospital, patient continued to be disorganized and paranoid. She had no prior psychiatric history before this admission. Thus, the records support a score of 5 for this dimension. Dimension 6 (engagement) assesses a patientas understanding of their illness and treatment, and ability and willingness to engage in the treatment process. In this case, the patientas paranoid ideation and persecutory delusions prevented her from engaging in groups and milieu therapy in the hospital. She had great difficulty actively engaging in recovery due to her symptoms and disorganization. Thus, the records support a score of 5 for this dimension. These findings give the patient a composite score of 31, which is consistent with medically managed residence-based services or inpatient level of care. Per LOCUS, the patientas scores of 4 for risk of harm and 5 for functional status also support treatment at Level 6 medically managed residence-based services level of care. For these reasons, the inpatient psychiatric admission was medically necessary. Therefore, inpatient hospitalization care from 4/13/21 through 4/21/21 was medically necessary for the treatment of this patient.
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A 57-year-old male enrollee has requested reimbursement for CPT 43210 esophagogastroduodenoscopy with transoral incisionless fundoplication performed on 4/23/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. | Upheld | Experimental | Summary Reviewer 2
A 57-year-old male enrollee has requested reimbursement for CPT 43210 esophagogastroduodenoscopy with transoral incisionless fundoplication performed on 4/23/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. There is a lack of long-term data to show the efficacy and durability of the transoral incisionless fundoplication procedure over time in comparison to other therapies. Studies of the transoral incisionless fundoplication procedure are lacking a large sample size with randomization and blinding. The safety and efficacy of the intervention over time has not been proven. The transoral incisionless fundoplication procedure is not more likely to be beneficial for the patient compared to conservative measures, such as therapy with twice-daily proton pump inhibitors, or surgical intervention, such as Nissen fundoplication. The field of endoscopic fundoplication has gained popularity over the past few years, and in an attempt to create a less invasive procedure that mimics anti-reflux surgery with fewer side effects, transoral incisionless fundoplication was developed. Several initial reports on transoral incisionless fundoplication were encouraging and showed effectiveness in reducing typical and atypical gastroesophageal reflux disease symptoms, eliminating daily proton pump inhibitor dependence, as well as in normalizing distal esophageal pH. On the contrary, other early experiences reported substantial failure rates. The available data on the transoral incisionless fundoplication technique are of limited quality and extracted from uncontrolled studies with generally a short follow-up duration. In this case, although the patient has reportedly failed multiple proton pump inhibitors, the medical record documentation does not detail whether or not he has trialed all of the proton pump inhibitors at a maximum twice-daily dose. In a randomized controlled trial by Witteman and colleagues, a total of 60 were included. At six months, gastroesophageal reflux disease symptoms were more improved in the transoral incisionless fundoplication group compared with the proton pump inhibitor group, with a similar improvement of distal esophageal acid exposure compared with baseline. The pH normalization for transoral incisionless fundoplication group and proton pump inhibitor group was 50% and 63%, respectively. The authors concluded, aAlthough transoral incisionless fundoplication resulted in an improved gastroesophageal reflux disease-related quality of life and produced a short-term improvement of the anti-reflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved.a The adverse risks associated with the transoral incisionless fundoplication procedure are not substantially increased over other standard services, although this is a surgical intervention and thus carries significantly more risk than therapy with titration of proton pump inhibitor therapy. Therefore, CPT 43210 esophagogastroduodenoscopy with transoral incisionless fundoplication performed on 4/23/21 was not likely to have been more beneficial than other available standard therapy.
| 1 |
The parent of a 12-year-old female enrollee has requested authorization and coverage for surgery (ApiFix procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.
In the reference by Floman and colleagues, three adolescent females aged 13-16 years with curves between 43-53 and Risser sign of 1-4 underwent surgery with ApiFix. Two pedicle screws were inserted around the curve apex and the ratchet device was attached to the screws. No fusion was performed. Two weeks after surgery, the patients were instructed to perform exercises to correct the curve. Curves were reduced and maintained between 22- 33. Patients were pain-free and were able to perform their spinal exercises. Postoperatively, the expected gradual elongation of the device was observed. No curve progression was seen. The curves corrected with exercise and growth modulation. No | Overturned | Experimental | Summary Reviewer 1
The parent of a 12-year-old female enrollee has requested authorization and coverage for surgery (ApiFix procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollees condition than any available standard therapy. The physician reviewer found that the ApiFix procedure is a less invasive procedure compared to the standard rodding and fusion of idiopathic adolescent scoliosis. The procedure consists of pedicle screw based instrumentation inserted around the apex of the main scoliotic curve. There is a ratchet mechanism that elongates the device with postoperative exercises, resulting in a gradual curve correction. There is no need for a fusion. In the reference by Floman and colleagues, three adolescent females aged 13-16 years with curves between 43-53 and Risser sign of 1-4 underwent surgery with ApiFix. Two pedicle screws were inserted around the curve apex and the ratchet device was attached to the screws. No fusion was performed. Two weeks after surgery, the patients were instructed to perform exercises to correct the curve. Curves were reduced and maintained between 22- 33. Patients were pain-free and were able to perform their spinal exercises. Postoperatively, the expected gradual elongation of the device was observed. No curve progression was seen. The curves corrected with exercise and growth modulation. No complications were observed. There is sufficient support for the requested services in this setting. Therefore, the requested surgery (ApiFix procedure) is likely to be more beneficial than other available standard therapy.
| 1 |
A 53-year-old male enrollee has requested reimbursement for the wearable cardioverter defibrillator provided from 8/27/14 through 10/15/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition.
the patient is a 53-year-old male with a newly recognized cardiomyopathy in the setting of rapid atrial fibrillation and syncope on 8/19/14. | Overturned | Medical Necessity | Summary Reviewer
A 53-year-old male enrollee has requested reimbursement for the wearable cardioverter defibrillator provided from 8/27/14 through 10/15/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found review of the submitted documentation and relevant literature demonstrates the medical necessity for the services at issue. Based on the documentation provided for review, the patient is a 53-year-old male with a newly recognized cardiomyopathy in the setting of rapid atrial fibrillation and syncope on 8/19/14. The cause of the syncope is not certain and may have been due to a sustained ventricular dysrhythmia in this setting. Therefore, protection against the possibility of recurrent syncope from ventricular tachycardia by placement of a defibrillator is indicated and considered standard accepted practice in the medical community (Russo, et al). Defibrillator placement was also recommended by the provider treating the patient at the time. However, defibrillator placement needed to be delayed both to see if the patients cardiomyopathy was reversible after cardioversion out of atrial flutter and because his INR was too high. During this period of delay it was reasonable and appropriate, to prescribe an external wearable defibrillator to help protect against recurrent syncope. A prophylactic wearable external defibrillator is indicated since accepted criteria for an implantable defibrillator were met (unexplained syncope in setting of severe cardiomyopathy) and placement of an implantable defibrillator needed to be significantly delayed. Therefore, the wearable cardioverter defibrillator provided from 8/27/14 through 10/15/14 was medically necessary for the treatment of the patients medical condition. For the reasons provided, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| 1 |
A 49-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of atrial septal defect. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.
the patient is a 49-year-old male with a history of a cryptogenic renal infarction in 2015, migraine headaches and a patent foramen ovale. | Upheld | Experimental | Summary Reviewer 1
A 49-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of atrial septal defect. 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 based on the records provided, the patient is a 49-year-old male with a history of a cryptogenic renal infarction in 2015, migraine headaches and a patent foramen ovale. Although there is an association with patent foramen ovale and both cryptogenic strokes and migraines, it is not clear that this patient's renal infarction was due to paradoxical embolization (no deep vein thrombosis identified) and current literature does not consistently demonstrate improved outcomes with patent foramen ovale closure compared to medical therapy. A randomized prospective trial by Furlan and colleagues did not demonstrate relative benefit of patent foramen ovale closure compared to standard medical therapy. Therefore, at this time the use of percutaneous closure devices for treatment of a patent foramen ovale in the setting of a documented transient ischemic attack or cryptogenic stroke has not been established, except in specific circumstances where alternative therapies, such as when aspirin or warfarin are not tolerated, alternative therapies are contraindicated, alternative therapies have failed, or in a clinical trial. Given the medical literature cited above and the documentation submitted for review, the requested services are not likely to be more beneficial than any standard treatments for this patient 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 42-year-old female has requested reimbursement for Anser IFX Assay testing performed on 10/26/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 1
A 42-year-old female has requested reimbursement for Anser IFX Assay testing performed on 10/26/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case. In this clinical setting, measuring infliximab drug levels and antibodies to infliximab was appropriate. Although the reaction the patient had appeared to have been relatively mild, there is concern that with future infusions the severity of the reactions may escalate. The testing performed was indicated in order to accurately measure antibody levels. Thus, Anser IFX Assay testing was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| 0 |
A 61-year-old female enrollee has requested reimbursement for the monitored anesthesia care (MAC) services provide on 12/15/14 during a colonoscopy. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees colorectal screening. | Upheld | Medical Necessity | Summary Reviewer
A 61-year-old female enrollee has requested reimbursement for the monitored anesthesia care (MAC) services provide on 12/15/14 during a colonoscopy. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees colorectal screening. The physician reviewer found that MAC is often utilized when it is important to have a dedicated anesthesiologist or anesthesia provider present during a particular diagnostic or therapeutic procedure. There are several indications for MAC including the patients clinical condition, comorbidities, past medical history, and the potential need to convert to a general anesthetic. MAC also includes the administration of other medications and agents necessary for patient safety and to support vital physiologic functioning. More than conscious sedation, MAC is characterized and defined by the anesthesiologists assessment and management of a patients actual or anticipated physiologic derangements or medical problems that may occur during a procedure. In this patients case, there was no documentation of a particular medical issue or comorbid disease process that would have required MAC services instead of conscious sedation. Typically it is appropriate to perform a screening colonoscopy with conscious sedation. During conscious sedation, a physician supervises or personally administers sedatives and/or analgesic medications during a diagnostic or therapeutic procedure. In this case, conscious sedation would have been appropriate. Thus, the MAC services provided on 12/15/14 were not medically necessary for evaluation of this patients medical condition. Given these above discussion, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
| 1 |
patient is a 44-year-old female who has been diagnosed with severe Raynauds with
ulceration. The patient has requested authorization and coverage for Botox injectable 100 unit
every 90 days for a year.
This patient has documented findings
consistent with severe Raynauds disease, including digital ulceration of hands and toes. | Overturned | Medical Necessity | Summary Reviewer
The patient is a 44-year-old female who has been diagnosed with severe Raynauds with
ulceration. The patient has requested authorization and coverage for Botox injectable 100 unit
every 90 days for a year. The physician reviewer found that treatment of severe and refractory
Raynauds disease must be individualized based on clinical findings, presentation, and other
studies. As the presentation of the patient is advanced and rare, the literature has mainly case
reports and small studies supporting the use of Botox for severe and ulcerating Raynauds
disease, although more recently there have been larger clinical trials. Due to the patients low-
normal blood pressure, additional blood pressure agents (such as different calcium channel
blockers) are contraindicated because of hypotensive risk. This patient has documented findings
consistent with severe Raynauds disease, including digital ulceration of hands and toes. Recent
literature supports the use of Botox for Raynauds syndrome for systemic sclerosis. In addition, a
randomized controlled trial by Motegi and colleagues supported the efficacy of Botox for
treatment of Raynauds disease and decrease in ulcerations. Given the refractory nature of the
patients disease, the presence of ulcerations, which suggests potential loss of function if the
disease continues, and support for use of Botox from clinical trials, there is sufficient support for
Botox in this clinical setting. Therefore, Botox injectable 100 unit every 90 days for a year is
medically necessary for the treatment of this patient.
| 1 |
A 40-year-old female enrollee has requested authorization and coverage for posterior lumbar interbody fusion (PLIF) spinal surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees back pain.
. This patient reported a marked increase in her chronic low back pain and disability following a traumatic event in February 2016. She has reported persistent and worsening low back pain with increasing levels of disability interfering with activities of daily living and work ability. Clinical findings
with MRI and CT imaging evidence of nerve root compromise at the L4-5 and L5-S1 levels with bilateral pars defects at L5 and 4 mm lytic spondylolisthesis of L5 on S1. There was borderline instability documented at the L2-3 and L3-4 levels. Discogram confirmed concordant pain at the L4-5 level, with no concordant findings at L3-4. | Overturned | Medical Necessity | Summary Reviewer
A 40-year-old female enrollee has requested authorization and coverage for posterior lumbar interbody fusion (PLIF) spinal surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees back pain. The physician reviewer found that evidence-based medical guidelines and peer-reviewed literature support lumbar fusion in the setting of disc pathology and degenerative disease when associated with evidence of spinal instability or surgically-induced temporary intraoperative instability, chronic pain, and failure of conservative treatment. This patient reported a marked increase in her chronic low back pain and disability following a traumatic event in February 2016. She has reported persistent and worsening low back pain with increasing levels of disability interfering with activities of daily living and work ability. Clinical findings are consistent with MRI and CT imaging evidence of nerve root compromise at the L4-5 and L5-S1 levels with bilateral pars defects at L5 and 4 mm lytic spondylolisthesis of L5 on S1. There was borderline instability documented at the L2-3 and L3-4 levels. Discogram confirmed concordant pain at the L4-5 level, with no concordant findings at L3-4. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. The treating provider has planned complete facetectomies and foraminotomies to achieve adequate nerve root decompression which would result in temporary intraoperative instability in the pre-existent setting of spondylolisthesis and pars defects, and necessitate fusion. Therefore, the requested PLIF spinal surgery is medically indicated for the treatment of this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
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A 27-year-old female enrollee has requested authorization and coverage for Humatrope. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has been assessed with adult growth hormone deficiency. A review of the record indicates that the enrollee has been diagnosed with adult growth hormone deficiency. The enrollee reported that she has been taking the growth hormone since the end of 2010. In a letter dated 9/6/17, the provider reported that the enrollee had a pre-treatment of insulin like growth factor-1 (IGF-1) of 184 ng/mL with a mean of 237 and a range of 87-368. The provider reported that the enrollee started her growth hormone stimulation to assess for growth hormone deficiency and peaked at 5.5 ng/mL. The record indicates that the enrollee had been diagnosed with Cushings syndrome in 2009. The enrollee has requested authorization and coverage for Humatrope. The Health Insurer indicates that the requested medication is not medically necessary. Per the Health Insurer, the enrollee did not meet the Health Plans clinical criteria for the requested medication. | Overturned | Medical Necessity | Summary Reviewer
A 27-year-old female enrollee has requested authorization and coverage for Humatrope. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has been assessed with adult growth hormone deficiency. A review of the record indicates that the enrollee has been diagnosed with adult growth hormone deficiency. The enrollee reported that she has been taking the growth hormone since the end of 2010. In a letter dated 9/6/17, the provider reported that the enrollee had a pre-treatment of insulin like growth factor-1 (IGF-1) of 184 ng/mL with a mean of 237 and a range of 87-368. The provider reported that the enrollee started her growth hormone stimulation to assess for growth hormone deficiency and peaked at 5.5 ng/mL. The record indicates that the enrollee had been diagnosed with Cushings syndrome in 2009. The enrollee has requested authorization and coverage for Humatrope. The Health Insurer indicates that the requested medication is not medically necessary. Per the Health Insurer, the enrollee did not meet the Health Plans clinical criteria for the requested medication. Therefore, the Health Insurer denied coverage for the requested medication. At issue is whether the requested medication is medically necessary for treatment of this enrollees medical condition.I have determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be overturned.
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A 38-year-old male enrollee has requested authorization and coverage for chemotherapy administration into the peritoneal cavity via indwelling port or catheter (hyperthermic intraperitoneal chemotherapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 2
A 38-year-old male enrollee has requested authorization and coverage for chemotherapy administration into the peritoneal cavity via indwelling port or catheter (hyperthermic intraperitoneal chemotherapy. 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 there is a lack of support for the requested services in this clinical setting. The use of heated intraperitoneal chemotherapy for colon cancer with peritoneal carcinomatosis is not considered to be standard of care. The current medical literature does not support the requested services in this patients case. The National Comprehensive Cancer Network guidelines do not support hyperthermic intraperitoneal chemotherapy in this patients case. Therefore, the requested hyperthermic intraperitoneal chemotherapy is not likely to be of greater benefit than other treatment modalities. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 55-year-old male insured has requested authorization and coverage for thermal destruction of
the intraosseous basivertebral nerve, including the first two vertebral bodies, lumbar or sacral,
Intracept procedure (CPT 64628). The Health Insurer has denied this request indicating that the
requested services are considered investigational for the treatment of the insureds chronic back
pain.
. This patient is being treated for vertebrogenic low back pain and
vertebral endplate pain. He presented with low back pain with bilateral leg thigh numbness and
heaviness with prolonged standing. Flexing forward helps relieve the pain. Treatment with an
epidural steroid injection was helpful for about three weeks. Evaluation with MRI of the lumbar
spine demonstrated Modic 2 endplate changes at the lumbosacral junction. | Upheld | Experimental | Summary Reviewer 1
A 55-year-old male insured has requested authorization and coverage for thermal destruction of
the intraosseous basivertebral nerve, including the first two vertebral bodies, lumbar or sacral,
Intracept procedure (CPT 64628). The Health Insurer has denied this request indicating that the
requested services are considered investigational for the treatment of the insureds chronic back
pain. The physician reviewer found that according to the U.S. Food and Drug Administration
(FDA), the Intracept procedure is intended to be used in conjunction with radiofrequency
generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief
of chronic low back pain of at least six months duration that has not responded to at least six
months of conservative care and is accompanied by features consistent with type 1 or type 2
Modic changes on a magnetic resonance imaging (MRI). One study concluded that there is
moderate quality evidence demonstrating the safety and efficacy of the Intracept procedure in
reducing pain and disability in well-selected patients with chronic low back pain with type 1 or 2
Modic changes (Conger, et al.). This patient is being treated for vertebrogenic low back pain and
vertebral endplate pain. He presented with low back pain with bilateral leg thigh numbness and
heaviness with prolonged standing. Flexing forward helps relieve the pain. Treatment with an
epidural steroid injection was helpful for about three weeks. Evaluation with MRI of the lumbar
spine demonstrated Modic 2 endplate changes at the lumbosacral junction. Imaging significance
is further supported by Conger et al, evidence that suggests this procedure is effective in
reducing pain and disability in patients with chronic low back pain who are selected based on
type 1 or 2 Modic changes. However, also demonstrated on the MRI was disc and facet disease
with listhesis, relatively mild central stenosis, and at least moderate bilateral foraminal
narrowing. As noted by DeVivo and colleagues, selection of patients is based on a
multidisciplinary approach including both conventional Diagnostic Radiology and Nuclear
Medicine imaging. Overall, the records suggest that there are multiple plausible pathologic
sources of significant pain generation. Per Tieppo Francio and Sayed, finding the source of
chronic axial low back pain is clinically challenging, and often 80% of diagnoses are described as
non-specific low back pain, and in only 20% of cases, an anatomical source can be attributed.
The patient has reported low back and bilateral leg thigh numbness and heaviness, standing as
a pain-aggravating factor, and flexing forward as a pain-relieving factor. The patient was noted
to have an intact strength examination non-specific to any pathologic entities. Overall,
documentation is lacking regarding reasonably detailed and evidenced findings supportive of the
spinal vertebral bodies as being the overwhelming primary generators of the patients chronic
persistent pain. Therefore, the requested thermal destruction of the intraosseous basivertebral
nerve, including the first two vertebral bodies, lumbar or sacral, Intracept procedure (CPT 64628)
is not likely to be more beneficial for the treatment of the patients medical condition than any
available standard therapy.
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The patient is a 12-year-old female who was seen by a pediatric endocrinologist on 12/14/20. Her height was 146.0 cm, which is below the 35th percentile or -0.4
the norm for age and gender. The patientas parent has requested authorization and coverage for Norditropin FlexPro 30 mg/3 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 records document deceleration from the 75th to the 50th percentile in height between 4 and 6 years of age, after which her height had gone down to the 50th percentile and stayed at the 50th until she was seen by the endocrinologist. On the day of visit, the patientas height was 146 cm (34th percentile). The mid-parental target height is 171.45 cm. Her predicted adult height is 62.75a, which is -2 standard deviations below the genetic mean height. She has failed an initial clonidine stimulation test as well as a second stimulation test. Brain MRI noted asmall appearing concave pituitary gland measuring up to 3.7 mm in maximal height.a Small pituitary gland | Overturned | Medical Necessity | Summary Reviewer
The patient is a 12-year-old female who was seen by a pediatric endocrinologist on 12/14/20. Her height was 146.0 cm, which is below the 35th percentile or -0.41 standard deviations below the norm for age and gender. The patientas parent has requested authorization and coverage for Norditropin FlexPro 30 mg/3 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 that the submitted documentation supports the medical necessity of the requested medication. The records support poor growth, short stature relative to the mid-parental height and growth hormone deficiency. The records document deceleration from the 75th to the 50th percentile in height between 4 and 6 years of age, after which her height had gone down to the 50th percentile and stayed at the 50th until she was seen by the endocrinologist. On the day of visit, the patientas height was 146 cm (34th percentile). The mid-parental target height is 171.45 cm. Her predicted adult height is 62.75a, which is -2 standard deviations below the genetic mean height. She has failed an initial clonidine stimulation test as well as a second stimulation test. Brain MRI noted asmall appearing concave pituitary gland measuring up to 3.7 mm in maximal height.a Small pituitary gland can be seen in growth hormone deficiency and panhypopituitarism. Growth hormone therapy is medically indicates in this setting. Growth hormone deficiency was the first indication for recombinant human growth hormone approved by the U.S. Food and Drug Administration (FDA). In this case, the records document growth hormone deficiency upon performing the stimulation test. Therefore, Norditropin FlexPro 30 mg/3 mL is medically necessary for the treatment of this patient. | 1 |
A 59-year-old male enrollee has requested authorization and coverage of Harvoni for 12 weeks. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. | Overturned | Medical Necessity | Summary Reviewer
A 59-year-old male enrollee has requested authorization and coverage of Harvoni for 12 weeks. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines do not recommend deferring treatment in patients with illicit alcohol or drug use, and in fact prioritize patients who use intravenous drugs due to benefits in disease transmission reduction. The patient should be considered treatment-naive because he failed interferon rather than PEG-interferon. The guidelines recommend that non-cirrhotic treatment-naive patients, or those who failed PEG-interferon/ribavirin, should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For the reasons stated above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
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A 46-year-old female enrollee has requested reimbursement for Afirma Gene Expression Classifier testing performed on 9/6/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees thyroid nodule. | Overturned | Experimental | Summary Reviewer 1
A 46-year-old female enrollee has requested reimbursement for Afirma Gene Expression Classifier testing performed on 9/6/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees thyroid nodule. The physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign (Miller, et al). The Afirma Gene Expression Classifier utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures (Duick, et al). For these reasons, the Afirma Gene Expression Classifier testing performed on 9/6/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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A 49-year-old female enrollee has requested reimbursement for the arthrodesis, interbody fusion, discectomy, decompression and related services provided on 9/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees left arm pain and neck pain with cervical kyphotic deformity and grade 1 spondylolisthesis at C4-5. | Overturned | Medical Necessity | Summary Reviewer
A 49-year-old female enrollee has requested reimbursement for the arthrodesis, interbody fusion, discectomy, decompression and related services provided on 9/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees left arm pain and neck pain with cervical kyphotic deformity and grade 1 spondylolisthesis at C4-5. The physician reviewer found that the available medical records document the presence of degenerative spondylolisthesis and associated radiculopathy and myelopathy. Thus, anterior cervical discectomy and fusion was medically necessary in the presence of extensive degenerative disc disease with degenerative spondylolisthesis and clinical evidence of radiculopathy and myelopathy. However, the currently available evidence is insufficient to support the use of mesenchymal stem cells in this procedure (Khashan, et al; McAnany, et al). Given these findings, the surgery including the C4-5 anterior cervical discectomy and fusion using interbody PEEK cage and allograft, C5-6 anterior cervical discectomy and fusion using interbody PEEK cage and allograft, and C6-7 anterior cervical discectomy and fusion using interbody PEEK cage and allograft, bilateral foraminotomies at C4-5, C5-6, and C6-7, and placement of anterior cervical plate at C4-7 using NuVasive system, fluoroscopic guidance, and reduction of kyphotic deformity was appropriate, reasonable, and medically necessary, and the stem cell portion of the procedure of 9/6/16 was not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned. | 1 |
A 22-year-old female enrollee has requested reimbursement for burn wound treatment provided on 1/10/19 (CPT 15273, 15274, 15277 and 15278). The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. | Overturned | Experimental | Summary Reviewer 3
A 22-year-old female enrollee has requested reimbursement for burn wound treatment provided on 1/10/19 (CPT 15273, 15274, 15277 and 15278). The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports a portion of the services at issue. Patients with burns benefit from early debridement and facilitation of rapid re-epithelialization (ideally less than three weeks) to prevent hypertrophic scar and the development of contractures and other adverse sequelae. While skin grafts have long been the gold standard for burn treatment, skin substitutes have a well-established role in the treatment of superficial and some deep partial thickness burns. Suprathel is a fully synthetic porous membrane that conforms to the underlying wound bed and promotes epithelialization. For partial thickness burns, Suprathel is superior to skin grafting since it avoids a donor site and significant pain. The ability to heal the wound and the ultimate appearance of the healed wound are equivalent to standard of care. For full thickness burns, however, it is inappropriate to use Suprathel. In this case, Suprathel was used on both partial and full thickness burns. Thus, burn wound treatment (CPT 15273, 15274, 15277 and 15278) for the partial thickness burns provided on 1/10/19 was likely to have been more beneficial than other treatment options. However, the superior efficacy of burn wound treatment (CPT 15273, 15274, 15277 and 15278) for the full thickness burns has not been established.
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A 49-year-old male enrollee has requested authorization and coverage for intraosseous
basivertebral nerve ablation. The Health Insurer has denied this request and reported that the
requested service is investigational for the treatment of the enrollees chronic low back pain. | Overturned | Experimental | Summary Reviewer 1
A 49-year-old male enrollee has requested authorization and coverage for intraosseous
basivertebral nerve ablation. The Health Insurer has denied this request and reported that the
requested service is investigational for the treatment of the enrollees chronic low back pain. At
issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial for
treatment of the enrollee's condition than any available standard therapy. The physician reviewer
found that in a randomized control trial evaluating the effectiveness of intraosseous radiofrequency
ablation of the basivertebral nerve to standard care for the treatment of chronic low back pain in a
specific subgroup of patients suspected to have vertebrogenic related symptomatology, Khalil and
colleagues noted that the study showed clear statistical superiority for all primary and secondary
patient-reported outcome measures in the radiofrequency ablation arm compared with the standard
care arm. The authors noted that in comparing the radiofrequency ablation arm to the standard
care arm, there were statistically significant improvements in Oswestry Disability Index (ODI)
scores and in Visual Analogue Scores (VAS) in the treatment arm compared to the standard of
care arm. In a study reporting on the two-year clinical outcomes for patients with chronic low
back pain treated with radiofrequency ablation of the basivertebral nerve, Fischgrund and
colleagues noted clinically meaningful improvements in both ODI and VAS sustained at two years
following treatment. Lorio and colleagues note that guidelines by the International Society for the
Advancement of Spine Surgery support the use of intraosseous ablation of the basivertebral nerve
for chronic low back pain for patients who have had chronic low back pain for at least six months,
have tried and failed six months of non-surgical management, and demonstrate Modic changes on
at least one endplate on magnetic resonance imaging (MRI). In this case, the patient has a history
of several years of persistent non-radicular chronic low back pain that has been refractory to
multiple modes of standard care including physical therapy, medications, spinal injections of the
facet joints, medial branch nerves, and epidural steroid injections. In this clinical setting, current
medical literature supports the Intracept procedure as superior to standard care both in improving
pain scores and disability scores, with results lasting for at least two years. Therefore, intraosseous
basivertebral nerve ablation is likely to be more beneficial for treatment of the patients condition
than any available standard therapy.
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A 63-year-old male enrollee has requested authorization and coverage for Repatha. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees hyperlipidemia.
that this patient has been diagnosed with hyperlipidemia, documented obstructive coronary disease and documented inability to tolerate statin therapy. | Upheld | Medical Necessity | Summary Reviewer
A 63-year-old male enrollee has requested authorization and coverage for Repatha. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees hyperlipidemia. The physician reviewer found that this patient has been diagnosed with hyperlipidemia, documented obstructive coronary disease and documented inability to tolerate statin therapy. However, there is no reported trial or intolerance to ezetimibe. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. Since ezetimibe has been demonstrated to be safe, well-tolerated, effective at lowering LDL cholesterol, and associated with improved outcomes, it is medically appropriate to trial this medication prior to determining the need for a PCSK9 inhibitor such as Repatha. Repatha is not medically indicated at this time since the need for additional LDL lowering has not been documented while on ezetimibe. All told, Repatha 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 35-year-old female enrollee has requested reimbursement for (CPT code 86343) leukocyte histamine release test (LHR) dated on 10/20/15. The Health Insurer has denied this request indicating that the requested procedure are considered investigational for treatment of the enrollees chronic idiopathic urticaria | Upheld | Experimental | Summary Reviewer 1
A 35-year-old female enrollee has requested reimbursement for (CPT code 86343) leukocyte histamine release test (LHR) dated on 10/20/15. The Health Insurer has denied this request indicating that the requested procedure are considered investigational for treatment of the enrollees chronic idiopathic urticaria The physician reviewer found in contrast to acute urticaria, many cases of chronic urticaria have identifiable causes. According to current management guidelines for chronic urticaria, chronic autoimmune urticaria can be differentiated from idiopathic urticaria by the presence of auto-antibodies to IgE receptors, also named chronic urticaria index. The Chronic Urticaria (CU) Index is available from reference laboratories. Patients with a chronic urticaria and a positive functional test result for autoantibody to the immunoglobulin E (IgE) receptor, likely have an autoimmune basis for the diagnosis. The evaluation for an autoimmune process is necessary to identify non-allergic triggers for her symptoms. The implication of such distinction has direct impact on the choices of treatment, as to include immune modulating or suppressor agents in addition to the conventional antihistamines for the treatment of chronic urticaria. The presence of urticarial symptoms in this patient has been greater than two months and is considered chronic urticaria. Furthermore, the treating provider also determined that the cause of her chronic urticarial symptoms was unlikely to be allergic. Therefore, an evaluation for autoimmune causes is clinically reasonable and necessary. In conclusion, the service in review (CPT code 86343 - leukocyte histamine release test) is likely to be more beneficial for treatment of the enrollees medical condition than any available standard of care. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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A 30-year-old male enrollee has requested reimbursement for substance use residential treatment provided from 7/04/18 through 7/20/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.
The patients abuse of alcohol was impairing his daily routine and contributing to significant impairment across multiple domains of functionality. As such, specialty
. However, the patient completed an uncomplicated detoxification. He was maintaining sobriety and was motivated for recovery. His girlfriend was supportive. He had safe housing. Despite his comorbid obsessive-compulsive disorder, the patient did not have a | Overturned | Medical Necessity | Summary Reviewer
A 30-year-old male enrollee has requested reimbursement for substance use residential treatment provided from 7/04/18 through 7/20/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. The patients abuse of alcohol was impairing his daily routine and contributing to significant impairment across multiple domains of functionality. As such, specialty care was indicated. However, the patient completed an uncomplicated detoxification. He was maintaining sobriety and was motivated for recovery. His girlfriend was supportive. He had safe housing. Despite his comorbid obsessive-compulsive disorder, the patient did not have a psychiatric condition or medical illness that required placement at the residential level of care. Further, the patient had no history of chemical dependency treatment, such as sponsored community programming, outpatient counseling, anti-craving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment. This is significant in this case for two reasons. First, modern psychiatric practice favors treatment in the community, as outcome measures and therapeutic gains are optimized in this environment. Second, there was no evidence to suggest that similarly comprehensive, evidence-based services provided a less restrictive treatment setting for this stable, motivated and otherwise healthy patient would have been insufficient or inadequate at the time. With that said, discharge on a federal holiday would have incurred a needless gap in treatment and thus would have been inappropriate. The extra day also afforded opportunity to address his severe craving, as it appears that acamprosate was added the following day. On 7/05/18, the patients craving was mild. There was no mention of medication intolerability or non-adherence. His appearance was appropriate, and he had no impairment in memory, concentration or thought processing. In sum, the patient had improved with the treatment intervention. He was autonomous and was maintaining motivation for sobriety. Further, he had not failed a less restrictive treatment course during the episode of illness. As such, the substance abuse residential treatment services at issue were no longer medically necessary as of 7/05/18. Thus, substance use residential treatment provided on 7/04/18 was medically necessary, but not thereafter. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned. | 1 |
A 40-year-old female enrollee has requested reimbursement for Decision Dx melanoma gene assay performed on 10/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk of recurrence in cutaneous melanoma.
In this case the patient presented with a thin melanoma of 0.81 mm with | Upheld | Experimental | Summary Reviewer 2
A 40-year-old female enrollee has requested reimbursement for Decision Dx melanoma gene assay performed on 10/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk of recurrence in cutaneous melanoma. The physician reviewer found that in general, Decision Dx test is not the standard of care for evaluation of melanoma. In this case the patient presented with a thin melanoma of 0.81 mm with poor prognostic compounding factors of ulceration, mitoses, and regression seen on pathology. Typically, when a melanoma is thin, no further testing is required as the risk of spread is low. However, when a tumor shows mitoses and ulceration it can mean an aggressive histology and further testing like a sentinel lymph node biopsy (SNLB) can be indicated. A SNLB is an invasive procedure and does not provide as much information about risk of tumor metastasis as the Decision Dx test. Therefore, testing was medically reasonable for this patient with a thin melanoma and multiple unique features. All told, the Decision Dx melanoma gene assay performed on 10/15/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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A 63-year-old female enrollee has requested reimbursement for substance abuse inpatient detoxification and residential services provided from 9/26/16 through 10/20/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues.
By the time of the patients admission on 9/26/16, her last use of alcohol was on 9/21/16. Although she was said to have experienced a seizure with subsequent hospitalization, there were no
On admission to detoxification, she was not on any prophylactic anticonvulsant medication. The patient did not demonstrate any post-acute withdrawal symptoms described in either the history and physical, or the psychiatric evaluation. She was not a danger to herself or others.
was not agitated, manic, or psychotic. She suffered from hypertension and hyperlipidemia.
24 hours per day, seven days per week monitoring with medical, nursing, and dietary professionals. The patient has a history of an extended period of sobriety, with Alcoholics Anonymous attendance. | Upheld | Medical Necessity | Summary Reviewer
A 63-year-old female enrollee has requested reimbursement for substance abuse inpatient detoxification and residential services provided from 9/26/16 through 10/20/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that the documentation provided does not support the medical necessity for the services at issue in this clinical setting. By the time of the patients admission on 9/26/16, her last use of alcohol was on 9/21/16. Although she was said to have experienced a seizure with subsequent hospitalization, there were no medical records provided from which to ascertain the nature and severity of this seizure or the treatment of same. On admission to detoxification, she was not on any prophylactic anticonvulsant medication. The patient did not demonstrate any post-acute withdrawal symptoms described in either the history and physical, or the psychiatric evaluation. She was not a danger to herself or others. There were no emotional, behavioral, cognitive, or impulsive factors requiring inpatient detoxification level of care. She was not agitated, manic, or psychotic. She suffered from hypertension and hyperlipidemia. However, neither these medications nor did the upwards titration of Lexapro, required inpatient monitoring. She was underweight at 104 pounds but this was not a life threatening situation requiring 24 hours per day, seven days per week monitoring with medical, nursing, and dietary professionals. The patient has a history of an extended period of sobriety, with Alcoholics Anonymous attendance. There is no evidence to suggest that she could not have continued her recovery at an ambulatory level of care. Based on the records provided, this patient did not require 24 hours per day, seven days per week monitoring. As such, reimbursement for substance abuse inpatient detoxification and residential services provided from 9/26/16 through 10/20/16 were not medically necessary for the treatment of this patient. Therefore, based on the reasons stated above, the services at issue were not medically necessary for treatment of this patients medical condition. The Health Insurers denial should be upheld. | 1 |
The patient is a 42-year-old female with a history of chronic low back pain and numbness in her legs. Imaging studies have revealed grade 2 isthmic spondylolisthesis at L4-5 associated with severe bilateral neural foraminal narrowing, severe disc degeneration, and facet hypertrophy. The patient has failed non-operative treatment, including physical therapy, chiropractic care, home exercise program, analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and bracing. The provider has advised laminectomy and facetectomy/decompression, and posterior lumbar interbody fusion at L4-5 with instrumentation. | Overturned | Medical Necessity | Summary Reviewer
The patient is a 42-year-old female with a history of chronic low back pain and numbness in her legs. Imaging studies have revealed grade 2 isthmic spondylolisthesis at L4-5 associated with severe bilateral neural foraminal narrowing, severe disc degeneration, and facet hypertrophy. The patient has failed non-operative treatment, including physical therapy, chiropractic care, home exercise program, analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and bracing. The provider has advised laminectomy and facetectomy/decompression, and posterior lumbar interbody fusion at L4-5 with instrumentation. The physician reviewer found that the lumbar isthmic spondylolisthesis in adults is defined as the forward translation of a lumbar vertebra on top of another, resulting from a defect in the pars interarticularis. The spondylolisthesis can be graded by the degree of slip, which in this case is grade 2 or more than a quarter but less than a half of the diameter of the vertebral body. There is a history of chronic low back pain and sensory neurological deficit in the lower extremities, with imaging evidence of severe bilateral neural foraminal narrowing in the same distribution. There is severe degeneration of the L4-5 intervertebral disc and Modic type 2 endplate changes. The persisting low back pain and evidence of radiculopathy, corroborated by imaging studies, are indications for surgery. This is supported
by the medical literature. The surgical fusion requested is posterior lumbar interbody fusion, which is also supported by the literature. The study by Alhammoud and colleagues did not find any significant differences between anterior and posterior approaches to fusion of the lumbar spine for isthmic spondylolisthesis. The article by Noorian also supports surgery and discusses various surgical options. Therefore, the requested posterior lumbar interbody fusion at L4-L5 and one inpatient bed day are medically necessary for the treatment of this patient.[insert ANALYSIS AND FINDINGS]
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A 65-year-old male enrollee has requested reimbursement for gene testing provided on 9/26/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 2
A 65-year-old male enrollee has requested reimbursement for gene testing provided on 9/26/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. In sum, gene testing provided on 9/26/18 was not likely to have been more effective than other methods of evaluating this patient.
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A 41-year-old male has requested reimbursement for a wearable cardioverter defibrillator. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees non-ischemic cardiomyopathy. | Upheld | Experimental | Summary Reviewer 1
A 41-year-old male has requested reimbursement for a wearable cardioverter defibrillator. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees non-ischemic cardiomyopathy. The physician reviewer found there is a lack of support for the device at issue in this clinical setting. The current medical literature does not support an improvement of health outcomes when a wearable cardioverter defibrillator is deployed in the treatment of a newly diagnosed non-ischemic cardiomyopathy prior to 90 days of guideline-directed medical therapy. The device at issue was not likely to have been of greater benefit than any available standard therapy, which would include beta blockers, angiotensin receptor blockers and diuretics. The current standard of care requires 90 days of such therapy followed by a reassessment of ejection fraction. During the dates of service in dispute, this patient had not been medically treated for non-ischemic cardiomyopathy for 90 days. In sum, the wearable cardioverter defibrillator was not likely to have been superior over 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.
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A 42-year-old female enrollee has requested reimbursement for hip arthroscopy performed on 4/05/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees hip pain. The physician reviewer found that this patient underwent right hip arthroscopy on 4/05/18 for revision treatment of femoroacetabular impingement and synovial cyst. She was status post three prior right hip arthroscopic procedures for treatment of femoroacetabular impingement, labral tear, and synovial cyst, with persistent and worsening right hip pain. Functional limitations were documented in activities of daily living. Clinical examination findings were consistent with MRI evidence of a synovial mass, possible labral tearing, and mixed femoroacetabular impingement, and x-ray evidence of Tonnis grade 1 changes. She had tried and failed extensive conservative management, including activity modification, physical therapy, home exercise, injections, and NSAIDs. Surgery was recommended to include revision hip arthroscopy for lysis of adhesions, decompression of her femoroacetabular impingement, evaluation of her cartilage, and removal of lesion anterior to her hip joint. Operative findings confirmed mixed femoroacetabular impingement with subspine component, labral deficiency, loose bodies, synovial cyst, and chondromalacia of the anterior superior acetabulum and femoral | Overturned | Medical Necessity | Summary Reviewer
A 42-year-old female enrollee has requested reimbursement for hip arthroscopy performed on 4/05/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees hip pain. The physician reviewer found that this patient underwent right hip arthroscopy on 4/05/18 for revision treatment of femoroacetabular impingement and synovial cyst. She was status post three prior right hip arthroscopic procedures for treatment of femoroacetabular impingement, labral tear, and synovial cyst, with persistent and worsening right hip pain. Functional limitations were documented in activities of daily living. Clinical examination findings were consistent with MRI evidence of a synovial mass, possible labral tearing, and mixed femoroacetabular impingement, and x-ray evidence of Tonnis grade 1 changes. She had tried and failed extensive conservative management, including activity modification, physical therapy, home exercise, injections, and NSAIDs. Surgery was recommended to include revision hip arthroscopy for lysis of adhesions, decompression of her femoroacetabular impingement, evaluation of her cartilage, and removal of lesion anterior to her hip joint. Operative findings confirmed mixed femoroacetabular impingement with subspine component, labral deficiency, loose bodies, synovial cyst, and chondromalacia of the anterior superior acetabulum and femoral head. Current evidence based medical guidelines support arthroscopic hip revision surgery for residual femoroacetabular impingement for functional outcome improvement, including Cam decompression, identification and treatment of subspine impingement, labral preservation/reconstruction, and capsular preservation/plication. Therefore, hip arthroscopy provided on 4/05/18 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. | 1 |
A 30-year-old female enrollee has requested authorization and coverage for Adderall XR 90 mg daily. The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).
The provider notes that the patient has been stable on a dose of Adderall XR 90 mg daily for seven years. | Upheld | Experimental | Summary Reviewer 2
A 30-year-old female enrollee has requested authorization and coverage for Adderall XR 90 mg daily. The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found according to the U.S. Food and Drug Administration (FDA) approval for Adderall XR, there is no proven benefit with doses above 60 mg in adults with ADHD. The provider notes that the patient has been stable on a dose of Adderall XR 90 mg daily for seven years. High dose stimulants can be risky for substance induced psychosis, mania, anxiety and can also contribute or worsen cardiac conditions. All told, the requested Adderall XR 90 mg daily 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 dosage 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 56-year-old male enrollee has requested reimbursement and prospective authorization and coverage for radiation therapy for bone metastases. 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 metastatic prostate cancer. | Upheld | Medical Necessity | Summary Reviewer
A 56-year-old male enrollee has requested reimbursement and prospective authorization and coverage for radiation therapy for bone metastases. 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 metastatic prostate cancer. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. Based on the information submitted, the provider has not given a sufficient reason for the use of three-dimensional conformal technique in the treatment of this bone metastasis. Currently, there is a lack of clinical data in the medical literature to suggest that treatment with three-dimensional conformal technique offers a clinical benefit compared to conventional radiation therapy techniques in the palliative setting for uncomplicated bone metastases. Additionally, for uncomplicated bone metastases, the use of stereotactic body radiation therapy is not medically necessary. There is a lack of clinical guidelines that endorse the use of stereotactic body radiation therapy in the initial treatment of prostate cancer metastases. All told, radiation therapy for bone metastases was not and is not medically indicated for the treatment of this patient. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
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A 34-year-old male enrollee has requested authorization and coverage for intensity modulated radiation therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition.
In this case, the provider has submitted comparison planning, which showed the bowel receiving an unacceptably high dose with the standard three-d | Overturned | Medical Necessity | Summary Reviewer
A 34-year-old male enrollee has requested authorization and coverage for intensity modulated radiation therapy. 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 in this case, due to the tumor location in the high pelvis and lower abdomen, the area that requires treatment is surrounded by a large amount of small bowel. Intensity modulated radiation therapy can be utilized in these cases to improve sparing of the small bowel compared to standard three-dimensional treatment planning. In this case, the provider has submitted comparison planning, which showed the bowel receiving an unacceptably high dose with the standard three-dimensional planning. The bowel dose is significantly reduced with the intensity modulated radiation therapy planning. The delivery of standard three-dimensional planning in this case is likely to result in an unacceptably high risk of complications. The medical evidence supports the use of intensity modulated radiation therapy in this clinical setting to mitigate toxicities from treatment. Therefore, intensity modulated radiation therapy is medically necessary for the treatment of this patient. | 1 |
A 53-year-old female enrollee has requested reimbursement for the ColonSentry testing performed on 1/20/15. The Health Insurer has denied this request indicating that the diagnostic testing at issue is considered investigational for evaluation of the enrollees risk for colorectal cancer. | Upheld | Experimental | Summary Reviewer 2
A 53-year-old female enrollee has requested reimbursement for the ColonSentry testing performed on 1/20/15. The Health Insurer has denied this request indicating that the diagnostic testing at issue is considered investigational for evaluation of the enrollees risk for colorectal cancer. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines for screening for colon cancer do not include ColonSentry, or similar, testing for average or above average risk individuals. The NCCN recommendations are for either colonoscopy, stool based testing with high sensitivity guaiac based or immunochemical based testing or flexible sigmoidoscopy. There is a lack of medical literature to support the use of ColonSentry for colorectal cancer screening. 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.
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patient is a nine-year-old male with extreme short stature. Per the clinical notes, he has been growing below the third percentile since five years of age. The records document mild subclinical hypothyroidism and negative celiac panel.
This patient has a height that is more than 2.25 standard deviations below the mean for age and sex. He has extreme short stature that
This patients bone age gives him an estimated adult height which is | Overturned | Medical Necessity | Summary Reviewer
The patient is a nine-year-old male with extreme short stature. Per the clinical notes, he has been growing below the third percentile since five years of age. The records document mild subclinical hypothyroidism and negative celiac panel. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has a height that is more than 2.25 standard deviations below the mean for age and sex. He has extreme short stature that qualifies for treatment with growth hormone therapy, based on Pediatric Endocrine Society guidelines. This patients bone age gives him an estimated adult height which is significantly below his mid-parental target height of 173 cm. He will not be able to attain the parental height without growth hormone treatment. Therefore, Norditropin FlexPro 15 mg/1.5 ml is medically necessary for the treatment of this patient. | 1 |
A 53-year-old female enrollee has requested reimbursement for collagen cross links testing performed on 11/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of fragility fracture The | Upheld | Experimental | Summary Reviewer 3
A 53-year-old female enrollee has requested reimbursement for collagen cross links testing performed on 11/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of fragility fracture The physician reviewer found that the use of bone turnover markers (BTMs) for the treatment of osteoporosis is still being determined. There are large variations in the results using BTMs with only several being standardized. At this time, the interpretation of how to utilize BTMs are not standardized. National recommendations or guidelines are lacking as to its use in the evaluation and management of osteoporosis. There are multiple recent studies reviewing the use of BTMs. However, its clinical utility for monitoring osteoporosis is limited by inadequate appreciation of the sources of variability, by limited data for comparison of treatments using the same BTM and by inadequate quality control. IOF/IFCC recommend one bone formation marker (s-PINP) and one bone resorption marker (s-CTX) to be used as reference markers and measured by standardised assays in observational and intervention studies in order to compare the performance of alternatives and to enlarge the international experience of the application of markers to clinical medicine, (Vasikaran, et al). A recent review by Lee and Vasikaran did not include BTMs. The authors noted that Measurement of BTMs is currently not included in algorithms for fracture risk calculations due to the lack of data. Accordingly, the literature fails to demonstrate that the collagen cross links testing performed on 11/17/15 was of greater benefit than the available standard therapy for the evaluation of this patients medical condition.
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 41-year-old male enrollee has requested authorization and coverage for a spine procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition.
Half the patients received the radiofrequency ablation of the basivertebral nerve and the other half received standard care.
patient has vertebrogenic pain with Modic type 2 changes at L3-4 and L4-5. He has chronic low back pain over six months in duration with | Overturned | Experimental | Summary Reviewer 1
A 41-year-old male enrollee has requested authorization and coverage for a spine procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the Intracept procedure is a minimally invasive procedure of intraosseous basivertebral nerve ablation for treatment of chronic low back pain of vertebrogenic origin with Modic Type 1 or 2 vertebral endplate changes. Khalil and colleagues performed a randomized controlled trial comparing the effectiveness of radiofrequency ablation of the basivertebral nerve to standard care for the treatment of chronic low back pain. A total of 140 patients were involved in this study. The selection criteria included chronic low back pain for at least six months, and evidence of severe degenerative disc disease with Modic Type 1 or 2 endplate changes. Half the patients received the radiofrequency ablation of the basivertebral nerve and the other half received standard care. The minimally invasive radiofrequency ablation of the basivertebral nerve group showed significant improvement in pain and functional improvement at the three-month evaluation. This randomized controlled trial showed the safety and efficacy of the Intracept procedure for patients with vertebrogenic low back pain with Modic Type 1 and 2 endplate changes. This patient has vertebrogenic pain with Modic type 2 changes at L3-4 and L4-5. He has chronic low back pain over six months in duration with failed standard treatment. As such, he is a good candidate for the Intracept procedure. Therefore, the requested spine procedure is likely to be more beneficial for the treatment of the patientas medical condition than any available standard therapy.
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A 38-year-old female enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 10/04/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. | Overturned | Medical Necessity | Summary Reviewer
A 38-year-old female enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 10/04/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patients depression is treatment-resistant. Multiple antidepressants and augmentation strategies have not successfully brought on remission. George and colleagues showed that transcranial magnetic stimulation was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Avery and colleagues provided evidence that transcranial magnetic stimulation is a safe and effective treatment for major depressive disorder. Connolly and colleagues reported that transcranial magnetic stimulation was found to be safe and effective in both acute and maintenance treatment of patients with treatment-resistant depression. Transcranial magnetic stimulation is an effective treatment. It has been approved by the U.S. Food and Drug Administration for the treatment of patients with treatment-resistant major depressive disorder and is consistent with standards of good medical practice. Therefore, transcranial magnetic stimulation is medically necessary for the treatment of this patient. | 0 |
A 47-year-old female enrollee has requested reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck and shoulder pain.
Per 10/19/15 report, the patient was instructed to use ice as needed and to take NSAIDs at her discretion. The patients diagnosis on 7/6/16 included cervicalgia and pain in right shoulder. | Upheld | Medical Necessity | Summary Reviewer
A 47-year-old female enrollee has requested reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck and shoulder pain. The physician reviewer found that the American College of Occupational and Environmental Medicine (ACOEM) state that if manipulation does not bring improvement in three to four weeks, it should be stopped and the patient reevaluated. In this case, while the patient presented with subjective pain, the provider has not documented clinical assessments and evaluations to support continued treatments. Most importantly, the records do not include discussions on objective functional improvement as an indication for the extended duration of care. Per 10/19/15 report, the patient was instructed to use ice as needed and to take NSAIDs at her discretion. The patients diagnosis on 7/6/16 included cervicalgia and pain in right shoulder. Overall, the medical necessity for continued chiropractic care cannot be determined without documentation of objective functional improvement. Therefore, reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16 were not medically necessary for treatment of this patients medical condition. Based on the records provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | 1 |
A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/02/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. | Overturned | Experimental | Summary Reviewer 2
A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/02/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found the current literature supports the service at issue in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, digital breast tomosynthesis performed on 8/02/16 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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The patient is a 61-year-old male who has requested reimbursement for Oncotype Dx Prostate Cancer Assay performed on 3/31/20. The patient has requested reimbursement for Oncotype Dx Prostate Cancer Assay performed on 3/31/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. | Overturned | Medical Necessity | Summary Reviewer
The patient is a 61-year-old male who has requested reimbursement for Oncotype Dx Prostate Cancer Assay performed on 3/31/20. The patient has requested reimbursement for Oncotype Dx Prostate Cancer Assay performed on 3/31/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) recommends Oncotype Dx Prostate Cancer Assay post-biopsy for men with low or favorable intermediate risk disease. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN 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. This patient is considered to have low risk disease and would fit these criteria. It is considered a standard of care in guiding treatment decision making. There is sufficient support for the services at issue in this setting. Therefore, Oncotype Dx Prostate Cancer Assay performed on 3/31/20 was medically necessary for the evaluation of this patient.
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The parent of a two-year-old female enrollee has requested reimbursement for chromosomal microarray (CMA, CPT code 81229) testing performed on 1/26/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has had a history of breath holding episodes that have increased in it severity. | Overturned | Experimental | Summary Reviewer 1
The parent of a two-year-old female enrollee has requested reimbursement for chromosomal microarray (CMA, CPT code 81229) testing performed on 1/26/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has had a history of breath holding episodes that have increased in it severity. The physician reviewer found that the array-based comparative genomic hybridization, also known as CMA has become standard of care in assessing children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies. Until recently, it was a diagnostic test that was employed when the first-line investigation of karyotype (chromosome analysis) returned normal. However, over the last 10 years it has emerged as a first line investigation. The yield of this test is 8-17% and varies with the degree of cognitive impairment, the presence of dysmorphic features, and the presence of congenital anomalies. The medical literature indicates that this test has become an important and mainstream tool in the practice of clinical genetics. As early as 2007, its diagnostic utility had been convincingly demonstrated, such that experts in the field were recommending its inclusion in the evaluation of any child with intellectual disability. More recently, in a retrospective analysis by Henderson and colleagues, the clinical utility of this test was confirmed showing that 12.7% of patients meeting referral criteria had a pathogenic copy number variant identified on microarray, and that half of those results influenced management including pharmacological treatment, cancer-related screening or exclusion of screening, identifying contraindications, and referrals for further evaluation. Data have now emerged showing that actionable findings from chromosomal microarray justify its use. In particular, Olson and colleagues found at least 5% of individuals with epilepsy had pathogenic copy number variants. All told, the CMA testing (CPT code 81229) performed on 1/26/16 was likely to have been superior over other standard options. Based upon the information set forth above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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The parent of a 14-year-old female enrollee has requested authorization and coverage for lidocaine injection 10 mg and associated inpatient stay. The Health Insurer has denied this request and reported that the requested services and requested medication is investigational for the treatment of the enrollees medical condition. | Overturned | Experimental | Summary Reviewer 1
The parent of a 14-year-old female enrollee has requested authorization and coverage for lidocaine injection 10 mg and associated inpatient stay. The Health Insurer has denied this request and reported that the requested services and requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that patients with chronic migraine headache are frequently refractory to conventional pharmacotherapy, either prophylactic or abortive in nature. While there have been trials with intranasal lidocaine, which also has rapid systemic absorption, there is a body of literature that supports the use of lidocaine infusion with considerable improvement in the severity of the headache, lessened or absent dependence on other analgesic medication, and most importantly cessation of chronic daily headache for prolonged periods of time. The medical evidence supports the requested services and requested medication in this clinical setting. Therefore, lidocaine injection 10 mg and associated inpatient stay are likely to be superior over other treatment options.
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A 30-year-old female enrollee has requested reimbursement for the Anser ADA serological markers performed on 8/21/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for treatment of the enrollees medical condition.
this case, the patient was noted to be doing well at the time her Anser study on 8/2 | Upheld | Experimental | Summary Reviewer 1
A 30-year-old female enrollee has requested reimbursement for the Anser ADA serological markers performed on 8/21/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the Anser ADA serological markers testing performed on 8/21/15 was not likely to be more effective for this patient than other available options. There are few well controlled clinical trials to confirm that use of the adalimumab antibody testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al). In addition, it has not been established in the peer-reviewed literature whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Generally, diminished or suboptimal response to adalimumab can be managed in several ways such as shortening the interval between doses, increasing the dose, switching to a different anti-tumor necrosis factor (TNF) agent or switching to a non-anti-TNF agent based on clinical observation in lieu of Anser testing. In this case, the patient was noted to be doing well at the time her Anser study on 8/21/15. Given the above, 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.
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A 41-year-old male enrollee has requested authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer has denied this request indicating that the requested equipment is considered investigational for treatment of the enrollee who had sustained an injury to his upper right arm. The physician reviewer found that the patient is a 41-year-old male who has sustained a permanent right brachial plexus injury (BPI) resulting in functional paralysis of his dominant right arm. The patient was involved in a motorcycle accident injuring his upper right arm. The records also indicate that the patient has undergone conservative therapies to improve function of this limb. The patient requests authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer has denied this request indicating that the equipment is investigational for treatment of this patient.
patient has tried various standard options like splinting, surgery and static orthoses | Overturned | Experimental | Summary Reviewer 3
A 41-year-old male enrollee has requested authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer has denied this request indicating that the requested equipment is considered investigational for treatment of the enrollee who had sustained an injury to his upper right arm. The physician reviewer found that the patient is a 41-year-old male who has sustained a permanent right brachial plexus injury (BPI) resulting in functional paralysis of his dominant right arm. The patient was involved in a motorcycle accident injuring his upper right arm. The records also indicate that the patient has undergone conservative therapies to improve function of this limb. The patient requests authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer has denied this request indicating that the equipment is investigational for treatment of this patient. There is sufficient support in the medical literature for the efficacy of the requested equipment in this clinical setting. The equipment is to assist in upper extremity function for an individual with weakness but not paralysis of the upper limb. The current medical literature indicates that greater functional ability may occur, for motivated patients, from such a powered exoskeleton equipment when compared to traditional orthosis. The medical records outline extensive rehabilitation attempts in a tertiary care setting leading to the current request for a myoelectric exoskeleton to improve the patients upper extremity function. This patient has tried various standard options like splinting, surgery and static orthoses in attempt to restore function to his right arm. As such, the medical record, in this case, presents compelling evidence for the requested myoelectric orthotic device for treatment of this patients functional paralysis of his upper right limb. In sum, the myoelectric, upper extremity orthosis is likely to be more efficacious than other modalities available for treatment of this patient. Based upon the information set forth above, the requested equipment 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 34-year-old male enrollee has requested reimbursement and prospective authorization and coverage for substance abuse residential treatment center (RTC) services provided from 9/25/16 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 alcohol dependence.
the patient had few complaints as reported in the records provided for review as evidenced by the low CIWA scores of 1-2. The patient was not a danger to himself or others. He had no comorbid medical conditions except for the torn hip abductor for which he was awaiting surgical repair. He was anxious and had episodic depression.
He was psychiatrically stable to the extent that he did not need a 24-hour treatment at an RTC facility to render his care from 9/25/16 forward.
. He was internally motivated and the psychiatry notes on 9/19/16 indicate that he was participating in treatment. He had sober supports in place. As of 9/25/16, | Upheld | Medical Necessity | Summary Reviewer
A 34-year-old male enrollee has requested reimbursement and prospective authorization and coverage for substance abuse residential treatment center (RTC) services provided from 9/25/16 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 alcohol dependence. The physician reviewer found the documentation demonstrates the patient had few complaints as reported in the records provided for review as evidenced by the low CIWA scores of 1-2. The patient was not a danger to himself or others. He had no comorbid medical conditions except for the torn hip abductor for which he was awaiting surgical repair. He was anxious and had episodic depression. However, there were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the RTC level of care. He was psychiatrically stable to the extent that he did not need a 24-hour treatment at an RTC facility to render his care from 9/25/16 forward. No new problems had arisen and there was no evidence to indicate that returning him to a less restrictive treatment environment would lead to destabilization. He was internally motivated and the psychiatry notes on 9/19/16 indicate that he was participating in treatment. He had sober supports in place. As of 9/25/16, the patient did not meet the American Society of Addiction Medicine (ASAM) clinical guidelines for RTC level of care and could have been successfully treated at an ambulatory level of care such as partial hospitalization program (PHP) or intensive outpatient program (IOP). Thus, the RTC services provided from 9/25/16 forward were not and are not medically necessary for treatment of this patients alcohol dependence. Based on the foregoing discussion, 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.
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The parent of a five-year-old male enrollee has requested reimbursement for albendazole provided on 3/01/18. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees medical condition.T | Upheld | Medical Necessity | Summary Reviewer
The parent of a five-year-old male enrollee has requested reimbursement for albendazole provided on 3/01/18. The Health Insurer has denied this request indicating that the medication at issue was 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 medication at issue. This patient does not have documented parasitic infection. There is some use of albendazole in children on the autistic spectrum that have gastrointestinal issues, but in the absence of positive cultures, this would be considered off-label usage and not consistent with the current standard of care. The medical evidence does not support the medication at issue in this clinical setting. Therefore, albendazole was not medically necessary in this patients case. Therefore, the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | 1 |
patient is a 38-year-old female with severe chronic pelvic pain. She underwent imaging of the pelvis, which showed dilated vessels, left larger than right. | Overturned | Medical Necessity | Summary Reviewer
The patient is a 38-year-old female with severe chronic pelvic pain. She underwent imaging of the pelvis, which showed dilated vessels, left larger than right. The physician reviewer found that this patient has clinical findings and imaging studies suggestive of pelvic congestion syndrome. There is limited data regarding the standard of care or optimal strategy to manage this diagnosis. For women with pelvic congestion syndrome, invasive treatment is an appropriate option. However, since randomized trials have not been performed, an optimal procedure is not known. As in this case, gonadal vein embolization is an accepted practice in the medical community. Case reports have shown the benefit of this procedure. The reported technical success rates of ovarian vein embolization range from 89 to 100 percent with clinical success rates of 58 to 100 percent (follow-up period of up to five years). Complication rates of 4 to 8 percent have been reported for ovarian vein embolization. Gonadal vein embolization is safe, well-tolerated, and allows for a minimally invasive approach. Thus, vascular embolization is medically necessary for the treatment of this patient. | 1 |
A 46-year-old male enrollee has requested reimbursement for emergency services provided on 7/2/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found the patient is a 46-year-old male who was evaluated in the emergency department at 14:31 on 7/2/17 with complaints of chest discomfort that had persisted for a couple of weeks. His pain was intermittent, and radiated to his left arm and jaw. He described his pain as heaviness and pressure that was moderate in intensity. His pain was accompanied by shortness of breath and diaphoresis. He had experienced tingling to the left face. The patient indicated that he initially thought his symptoms were due to discontinuing temazepam, but his symptoms had persisted. The patients medical history is significant for diabetes. His family history includes coronary artery disease. Differential diagnoses considered included unstable angina, pulmonary embolism, and atypical chest pain. The patients heart sounds were regular, normal perfusion was present and lungs were clear with unlabored respirations. An electrocardiogram (EKG) did not reveal any acute ischemia. A chest x-ray was negative for acute disease. Laboratory data was significant for an elevated D-dimer and a normal Troponin. A computed tomography (CT) angiogram of the chest did not show any evidence of pulmonary embolism. The patient was medicated with oral aspirin and sublingual nitroglycerin. He was admitted to observation unit on telemetry. The patient has requested reimbursement for emergency services provided on 7/2/17. The Health Insurer | Overturned | Medical Necessity | Summary Reviewer
A 46-year-old male enrollee has requested reimbursement for emergency services provided on 7/2/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found the patient is a 46-year-old male who was evaluated in the emergency department at 14:31 on 7/2/17 with complaints of chest discomfort that had persisted for a couple of weeks. His pain was intermittent, and radiated to his left arm and jaw. He described his pain as heaviness and pressure that was moderate in intensity. His pain was accompanied by shortness of breath and diaphoresis. He had experienced tingling to the left face. The patient indicated that he initially thought his symptoms were due to discontinuing temazepam, but his symptoms had persisted. The patients medical history is significant for diabetes. His family history includes coronary artery disease. Differential diagnoses considered included unstable angina, pulmonary embolism, and atypical chest pain. The patients heart sounds were regular, normal perfusion was present and lungs were clear with unlabored respirations. An electrocardiogram (EKG) did not reveal any acute ischemia. A chest x-ray was negative for acute disease. Laboratory data was significant for an elevated D-dimer and a normal Troponin. A computed tomography (CT) angiogram of the chest did not show any evidence of pulmonary embolism. The patient was medicated with oral aspirin and sublingual nitroglycerin. He was admitted to observation unit on telemetry. The patient has requested reimbursement for emergency services provided on 7/2/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis.At issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.The patients symptoms on 7/2/17 did meet the prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his or her health. This patient presented to the emergency department after experiencing intermittent chest pain for a few weeks. Symptoms of paresthesia with an elevated D-dimer made pulmonary embolism a consideration. His symptoms were classic for acute coronary syndrome as they were described as intermittent, radiating to his arm and jaw, and associated with shortness of breath and diaphoresis. In addition, the patients significant risk factors for coronary artery disease included diabetes, obesity, and a family history of coronary artery disease. These factors, combined with the patients age, would generate a history, EKG, age, risk factors and initial troponin (HEART) score of 4. Admission is recommended for such patients as a score of 4 is associated with a 12-16% risk of an adverse cardiac event. A patient who experiences intermittent chest pain with significant cardiac risk factors meets prudent layperson criteria for an emergency. Thus, the services provided on 7/2/17 were for treatment of an emergency medical condition.
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A 64-year-old female enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation. 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. | Upheld | Experimental | Summary Reviewer 3
A 64-year-old female enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation. 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 based on the documentation submitted for review, there is a lack of sufficient rationale for the use of proton therapy in the palliative setting for the treatment of an orbital lesion. Currently, there is a lack of clinical data in the medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the palliative setting for multiple myeloma. In addition, there is a lack of literature that compares clinical outcomes of proton beam radiotherapy compared to standard photon techniques for orbital metastases. The standard approach in this clinical setting is standard photon techniques. Also, the American Society of Radiation Oncology (ASTRO) emerging technology committee report on proton therapy does not mention the use of proton therapy for this condition (Allen, et al). A comparison of proton technique versus three-dimensional (3D) conformal technique has been submitted and reviewed against published and generally-accepted normal tissue constraints. The comparison shows no clinically relevant reduction in radiation doses with the proton plan compared to the standard intensity modulated plan. The doses that have been provided to show the difference between photon and proton plans are both within acceptable ranges. Although the 3D dose to certain critical structures may be higher, it is still considered an acceptable plan by Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) dose criteria and the difference between the two plans is not considered clinically significant (Marks, et al). 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 this setting. Based on these reasons, proton beam therapy was not and is not likely to be more beneficial than standard treatment with photon techniques. 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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The parent of an eight-year-old female enrollee has requested authorization and coverage for Nutropin AQ Nuspin. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature.
This patient meets the criteria for idiopathic short stature and has shown good response to growth hormone treatment with adequate monitoring and minimal side effects. She also had a poor pre-treatment growth velocity and | Overturned | Medical Necessity | Summary Reviewer
The parent of an eight-year-old female enrollee has requested authorization and coverage for Nutropin AQ Nuspin. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature. The physician reviewer found that in 2003, the U.S. Food and Drug Administration (FDA) approved the use of growth hormone therapy for idiopathic short stature or non-growth hormone-deficient short stature defined as height standard deviation less than or equal to -2.25 or less than or equal to 1.2nd percentile or age and gender. This patient meets the criteria for idiopathic short stature and has shown good response to growth hormone treatment with adequate monitoring and minimal side effects. She also had a poor pre-treatment growth velocity and poor final height prediction, which is greater than two standard deviations below the mid-parental height. Continued growth hormone therapy is medically appropriate in this clinical setting. Thus, Nutropin AQ Nuspin is 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 54-year-old male enrollee has requested reimbursement for high-intensity focused ultrasound (HIFU) performed on 6/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees prostate cancer. | Upheld | Experimental | Summary Reviewer 1
A 54-year-old male enrollee has requested reimbursement for high-intensity focused ultrasound (HIFU) performed on 6/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that HIFU has been increasingly been used for treatment of localized prostate cancer within the last decade. It has the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity. Potential candidates are patients with low to moderate risk prostate cancer. The available literature mainly consists of prospective case series and retrospective studies showing short-term to intermediate-term outcomes for localized prostate cancer. There is a paucity of controlled trials available for analysis, and a lack long-term survival data is available. American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology guidelines note clinicians should inform low-risk prostate cancer patients who are considering focal therapy or HIFU that these interventions are not standard care options because comparative outcome evidence is lacking. Therefore, HIFU provided on 6/28/16 was not likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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A 43-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) therapy from 10/23/15 through 11/24/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.
. The patient began TMS therapy on 8/21/15 with a PHQ9 of 27/27, indicating a severe level of depression. Over the course of TMS treatment, the documentation noted that her depression lifted, as reflected by her subsequent PHQ9 scores and subjective reports. By 10/23/15, she reported significant improvement with a PHQ9 of 5/27. On 10/7/15, she received TMS session #30, and on 10/28/15 she received TMS session #6 of tapering. The documentation noted that the Health Insurer had approved 30 TMS sessions with an additional six for tapering. | Overturned | Medical Necessity | Summary Reviewer
A 43-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) therapy from 10/23/15 through 11/24/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is support for a portion of the services at issue in this clinical setting. The patient began TMS therapy on 8/21/15 with a PHQ9 of 27/27, indicating a severe level of depression. Over the course of TMS treatment, the documentation noted that her depression lifted, as reflected by her subsequent PHQ9 scores and subjective reports. By 10/23/15, she reported significant improvement with a PHQ9 of 5/27. On 10/7/15, she received TMS session #30, and on 10/28/15 she received TMS session #6 of tapering. The documentation noted that the Health Insurer had approved 30 TMS sessions with an additional six for tapering. The sessions from 10/23/15 through 10/28/15 were medically necessary, as she showed improvement while in active treatment. However, the services from 10/29/15 through 11/24/15 were not medically necessary for treatment. There is a lack of evidence, in the body of literature, to support the medical necessity of continued long term TMS treatment, in this patients case. As such, the TMS sessions from 10/23/15 through 10/28/15 were medically necessary but not thereafter. Therefore, for the reasons stated above, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
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A 35-year-old male enrollee has requested reimbursement for substance abuse residential treatment from 6/17/15 through 7/03/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.
. This patient had a concerning history of alcohol use that began in late adolescence. His drinking was dominating multiple functional domains, impaired his sociability and relationships, and resulted in an arrest with subsequent probation. He lacked insight into the extent of his addiction as he thought he could resume drinking alcohol. | Overturned | Medical Necessity | Summary Reviewer
A 35-year-old male enrollee has requested reimbursement for substance abuse residential treatment from 6/17/15 through 7/03/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue. Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. This patient had a concerning history of alcohol use that began in late adolescence. His drinking was dominating multiple functional domains, impaired his sociability and relationships, and resulted in an arrest with subsequent probation. He lacked insight into the extent of his addiction as he thought he could resume drinking alcohol. Thus, 11 days of residential treatment was an insufficient duration of treatment to address the patients convoluted relationship with alcohol and mobilize the meaningful therapeutic momentum needed to foster sustained sobriety. In the absence of residential programming, the patient would have more than likely returned to a pathological and self-defeating pattern of alcohol consumption. The comprehensive services were delivered in accordance with an individual treatment plan. Further, the services were reasonably expected to improve the patients condition and prevent a more serious episode of illness. The placement facilitated active treatment and also provided opportunity to further explore and treat his anxiety, which was identified as a trigger for his drinking. Finally, the duration of services was consistent with community practice standards. All told, substance abuse residential treatment services provided from 6/17/15 through 7/03/15 were medically indicated for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
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A 37-year-old male enrollee has requested reimbursement and prospective authorization and coverage for assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease.
, the patient underwent a total of nine serial testing of fecal calpr | Upheld | Experimental | Summary Reviewer 2
A 37-year-old male enrollee has requested reimbursement and prospective authorization and coverage for assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that calprotectin, when measured in feces, is commonly used in clinical practice to differentiate between non-organic and inflammatory intestinal disorders, especially to identify inflammatory bowel disease (IBD). Fecal calprotectin may also be useful to monitor patients with IBD under treatment and to predict the risk of recurrence of active disease prior to clinical relapse (Burri and Beglinger). While one time fecal calprotectin testing may have clinical utility, a series of calprotectin assays does not (Bourdillon, et al). In this case, the patient underwent a total of nine serial testing of fecal calprotectin from 12/7/15 through 12/26/16. This serial testing has not proven adequately correlative with the patients other inflammatory markers. For the reasons provided, the assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing was not and is 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 and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
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patient is a 52-year-old female with a history of cervical dystonia and secondary cervicogenic
headaches. The patient received Xeomin injections on 12/23/22. The Health Insurer denied the
treatment at issue as not medically necessary for the treatment of the patients medical condition.
In this case, the patient had a history of cervical dystonia with secondary cervicogenic headaches.
The patient had tried several treatment options, including include indomethacin, oxycodone,
Zanaflex, Advil, Nurtec, left C3-5 facet injections, dry needling, and trigger point injections. | Overturned | Medical Necessity | Summary
The patient is a 52-year-old female with a history of cervical dystonia and secondary cervicogenic
headaches. The patient received Xeomin injections on 12/23/22. The Health Insurer denied the
treatment at issue as not medically necessary for the treatment of the patients medical condition.
This denial is the subject of this appeal and determination. The physician reviewer found that
according to the recent American Academy of Neurology (AAN) practice guidelines, botulinum
toxin is accepted as first-line treatment for patients with cervical dystonia. Xeomin is a preparation
of botulinum toxin approved by the U.S. Food and Drug Administration (FDA). Per the AAN
guidelines, Xeomin is likely safe and effective for the treatment of patients with cervical dystonia.
In this case, the patient had a history of cervical dystonia with secondary cervicogenic headaches.
The patient had tried several treatment options, including include indomethacin, oxycodone,
Zanaflex, Advil, Nurtec, left C3-5 facet injections, dry needling, and trigger point injections.
Xeomin is accepted as a first-line treatment option for this patients condition. Therefore, the
Xeomin injections received on 12/23/22 were medically necessary for the treatment of this patient.
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A 48-year-old female enrollee has requested reimbursement for lab testing (Factor V Leiden genetic testing) provided on 12/16/14. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. | Upheld | Experimental | Summary Reviewer 2
A 48-year-old female enrollee has requested reimbursement for lab testing (Factor V Leiden genetic testing) provided on 12/16/14. 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 the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Although there is an increased risk of a thrombotic event with hormone use, in the population as a whole the overall risk of a thrombotic event is still small. This low risk to the general population is especially true if women with known risk factors are pulled from the general population and screened. Currently, given these facts, the current recommendations suggest that only those with specific risk factors should be screened. The documentation submitted for review does not demonstrate that the patient has had a venous thrombosis, pulmonary embolism, family histories, or adverse pregnancy events. All told, the testing at issue was not likely to be superior for evaluation of the patients medical condition than other modalities.
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A 49-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 3/15/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who underwent a breast screening evaluation. | Overturned | Experimental | Summary Reviewer 1
A 49-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 3/15/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who underwent a breast screening evaluation. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with dense tissue such as this patient. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and overall increase in diagnostic accuracy compared to two-dimensional imaging alone. The medical evidence supports the service at issue in this clinical setting. All told, breast tomosynthesis performed on 3/15/17 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
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The representative of a deceased female enrollee has requested reimbursement for inpatient services provided from 8/17/17 through 9/11/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who has a history of cirrhosis of the liver.
of 8/17/17. The patient had stabilized as of 8/15/17. She did not require high-flow oxygen and was hemodynamically stable. She was working with therapy and did not have active infections. Her mental status was described as waxing and waning with mild confusion, which was expected for her medical condition. The laboratory studies were stable, with a stable hemoglobin, and she was tolerating oral medications. There was no documentation of active bleeding or respiratory distress. | Upheld | Medical Necessity | Summary Reviewer
The representative of a deceased female enrollee has requested reimbursement for inpatient services provided from 8/17/17 through 9/11/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who has a history of cirrhosis of the liver. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. There is limited records to support an inpatient admission as of 8/17/17. The patient had stabilized as of 8/15/17. She did not require high-flow oxygen and was hemodynamically stable. She was working with therapy and did not have active infections. Her mental status was described as waxing and waning with mild confusion, which was expected for her medical condition. The laboratory studies were stable, with a stable hemoglobin, and she was tolerating oral medications. There was no documentation of active bleeding or respiratory distress. The records do not demonstrate that the patient required ongoing inpatient care during the dates of service in dispute. All told, inpatient services provided from 8/17/17 through 9/11/17 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | 1 |
Subsets and Splits