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Summary Reviewer 1
A 60-year-old male has requested reimbursement for gene testing provided on 11/07/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by the staging system spelled out by Balch. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or class 2 based on the risk of metastasis. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, gene testing provided on 11/07/17 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 02f2be6e8eaae28e49c159a676bef1dc | ./data/processed/ca_cdi/summaries/18-6455.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 60-year-old male has requested reimbursement for gene testing provided on 11/07/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The results of this testing were unlikely to have altered treatment recommendations. There is a paucity of evidence from the literature that tailored follow-up according to these test results has an impact on long-term outcomes. Furthermore, prospective randomized studies to determine recurrence risk is lacking for this test. In sum, gene testing provided on 11/07/17 was not likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 02f2be6e8eaae28e49c159a676bef1dc | ./data/processed/ca_cdi/summaries/18-6455.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 60-year-old male has requested reimbursement for gene testing provided on 11/07/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network (NCCN) guidelines states 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. Thus, gene testing provided on 11/07/17 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 02f2be6e8eaae28e49c159a676bef1dc | ./data/processed/ca_cdi/summaries/18-6455.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 1
A 61-year-old female enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the requested services in this clinical setting. The patient has obstructive sleep apnea and has no nasal obstruction. Drug induced sleep endoscopy showed no concentric collapse at velum and primarily anterior posterior collapse. The patient has not been able to tolerate the continuous positive airway pressure device. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device given the intolerance to continuous positive airway pressure, anterior posterior collapse, and body mass index within FDA criteria. Therefore, 64568 and 0466T are likely to be more beneficial than other treatment options.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 49f11ca3731a3fddffe9b45be7cd9e03 | ./data/processed/ca_cdi/summaries/19-6924.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 61-year-old female enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that multiple studies indicate that hypoglossal nerve stimulation is a safe and effective treatment option for moderate-severe obstructive sleep apnea patients who have failed medical therapy. The STAR trial showed that upper airway stimulation provides significant improvement in sleep-related quality of life outcome measures. Safety and stable outcome results for the hypoglossal nerve stimulation/Inspire upper airway stimulation system have been demonstrated over 48 months in the peer-reviewed literature. In sum, 64568 and 0466T are likely to be more beneficial than other treatment options.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 49f11ca3731a3fddffe9b45be7cd9e03 | ./data/processed/ca_cdi/summaries/19-6924.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 61-year-old female enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this patients case. She has moderate obstructive sleep apnea. The documentation notes that the patient is intolerant to continuous positive airway pressure therapy. The records do not clearly establish that the patient is not a candidate for oral appliance therapy. Mild to moderate obstructive sleep apnea has been shown to be responsive to oral appliance therapy. Thus, 64568 and 0466T are not likely to be more beneficial than other treatment options.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 49f11ca3731a3fddffe9b45be7cd9e03 | ./data/processed/ca_cdi/summaries/19-6924.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The parent of a 12-year-old female enrollee has requested reimbursement for inpatient hospitalization provided from 11/14/16 through 11/17/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees complex regional pain syndrome of her right lower extremity. The physician reviewer found that based on the presented clinical records submitted for review, the inpatient hospitalization provided from 11/14/16 through 11/17/16 was medically necessary for treatment of the patients medical condition. Complex regional pain syndrome type 1 is a pain syndrome of the extremities characterized by pain, edema, limited range of motion, skin changes, and vasomotor instability. There is typically some inciting event, after which the symptoms occur. Prompt diagnosis and a multidisciplinary approach to treatment have been shown to facilitate recovery (Harris, et al; Wasner, et al). In this case, the patient presented with an acute on chronic exacerbation of her complex regional pain syndrome, refractory to her usual medications, addition of medications, and outpatient pudendal nerve block. Following failure of outpatient management and reports of extreme pain rated at 11/10, she was admitted for ketamine infusion and CT-guided pudendal nerve block. Ketamine is used to treat chronic pain syndromes, particularly those with a neuropathic component. Because neuropathic pain involves N-methyl-D-aspartate receptor upregulation, especially in cases of central sensitization, and ketamine is thought to inhibit this receptor, it has been used in appropriately chosen cases to provide relief. Given that the patient failed outpatient management, acute inpatient management provided at a higher level of care was clinically indicated for this patient. As such, the services at issue have been established as medically necessary for treatment of the patients medical condition. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 451af92e2c2bb6a4f5e564e60ac3ec82 | ./data/processed/ca_cdi/summaries/18-6233.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 47-year-old female enrollee has requested reimbursement and prospective authorization and coverage for continued outpatient day treatment program/recovery facility care provided from 1/24/15 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 status post intracranial hemorrhage. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the services at issue. The patient sustained deficits of physical and cognitive function after a stroke in June 2014. She entered into acute rehabilitation with treatment continuing in the form of a day treatment program through May 2015. Micklewright and colleagues have shown that entry into a comprehensive day treatment program 0-6 months after acquired brain injury is associated with better outcomes than later entry. The services in dispute are day treatment therapies provided from 1/24/15 and onward, seven months post-stroke and forward. The records submitted for review do not demonstrate the patient has deficits of self-care (ADLs) and functional mobility requiring continued intensive rehabilitation beyond 1/24/15. Based on the medical records submitted and the peer-reviewed literature, the continued outpatient day treatment program/recovery facility care provided from 1/24/15 forward was not and is not medically necessary for treatment of the patients medical condition. For the reasons provided, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 15d6658498b3688d54831226a002b0d3 | ./data/processed/ca_cdi/summaries/15-4170.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
The patient is a 58-year-old female with gastroesophageal reflux disease (GERD). Computed tomography (CT) scan of the abdomen on 3/14/17 showed mild wall thickening of the distal esophagus and a small hiatal hernia. Esophagogastroduodenoscopy (EGD) on 7/11/17 showed and irregular squamocolumnar junction at 40 cm, 1 cm hiatal hernia, scattered erosions in the gastric body and antrum, and normal appearing duodenal bulb and second portion of the duodenum. Biopsies showed acute and chronic inflammation at the gastroesophageal junction, Barretts esophagus, and minimal chronic gastritis. Esophagram on 9/19/17 showed normal esophageal peristalsis, no ulceration or stricture, and episodes of gastroesophageal reflux. EGD on 9/26/17 showed a normal-appearing esophagus, a Hill Grade 2 lower esophageal valve, and mild gastritis. Bravo pH study on 9/26/17 showed an elevated DeMeester score of 39.7, consistent with increased acid exposure. Per the providers note dated 10/9/17, the patient had a partial response to proton pump inhibitor therapy. The patient has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational. Overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the requested LINX is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | c1f77202729a3bd06017b5a38419095b | ./data/processed/ca_cdi/summaries/18-6368.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
The patient is a 58-year-old female with a history of gastroesophageal reflux disease (GERD). Evaluation has included esophagogastroduodenoscopy (EGD) in 2017 with a small hiatal hernia, irregular Z-line and histologically mild acute and chronic esophagitis, and minimal to mild Helicobacter pylori-negative gastritis. In 2017, pH testing performed off acid blocker therapy identified a composite DeMeester score of 39.7 and zero correlation of acid reflux events with heartburn. The patient has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational. The LINX device received U.S. Food and Drug Administration (FDA) premarketing for patients with GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. This patient has GERD based on pH recording and radiographic criteria. However, she does not have evidence of advanced esophagitis nor was there correlation noted between acid reflux events and heartburn. Given that only 64% of patients achieved either normalization of or at least 50% reduction in esophageal acid exposure with LINX (1), this patients lack of correlation of symptoms with acid exposure does not support an indication for the requested procedure. Thus, the requested LINX procedure is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | c1f77202729a3bd06017b5a38419095b | ./data/processed/ca_cdi/summaries/18-6368.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
The patient is a 58-year-old female under evaluation and treatment for GERD. The patient is considered to have both typical and atypical symptoms with only a partial response to proton pump inhibitor (PPI) therapy. Upper endoscopy showed no Barretts and a 1 cm hiatal hernia without esophagitis. Barium esophagram suggested normal peristalsis. The patient underwent a pH study of the esophagus which was positive for pathologic reflux with acidification of the esophagus 13% of the time. There was a poor correlation between acid reflux events and the timing of symptoms. The patient has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational. The U.S. Food Drug Administration (FDA) approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. This patient has a poor association between symptoms and episodes of pathologic reflux. In addition, the patient has atypical symptoms and only a partial response to PPI therapy. These findings indicate that the patient will not experience improvement with a surgical approach to her reflux disease beyond what she has experienced with PPI therapy. For these reasons, the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | c1f77202729a3bd06017b5a38419095b | ./data/processed/ca_cdi/summaries/18-6368.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 47-year-old male enrollee has requested reimbursement for the magnetic resonance imaging (MRI) of the pelvis provided on 5/19/17. The Health Insurer has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees prostate cancer. The physician reviewer found that repeat imaging in this clinical setting to evaluate the patient for a change in the size of the tumor focus as well as the capsule and surrounding structures is state of the art medicine. Even though the patients PSA has remained stable the patient has a history of proven malignancy even in the face of a low PSA level. Currently, prostate MRI using a 3 Tesla magnet and restriction spectrum imaging (RSI) or diffusion weighted imaging is the most sensitive way to image the prostate and the surrounding anatomy. Based on the findings on this follow-up MRI, if there had been a change in the size of the tumor or if another focus of restricted diffusion was visualized, then the patient would likely have been referred for surgery. Given this support, an MRI of the prostate was indicated and MRI has been proven to be the most reliable means for further evaluation in this clinical setting. Accordingly, the MRI of the pelvis provided on 5/19/17 was medically necessary. For the reasons discussed, the service at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 160c9fac27c4c8091f8c6e853715cd35 | ./data/processed/ca_cdi/summaries/17-6076.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 53-year-old female enrollee has requested reimbursement for the bilateral three dimensional digital breast tomosynthesis provided on 10/16/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography alone. Overall, three dimensional digital breast tomosynthesis allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue. Moreover, the addition of breast tomosynthesis has been found to increase cancer detection. Thus, the digital breast tomosynthesis on 10/16/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 9da9bcd245b61b3f495d736a8b9d916b | ./data/processed/ca_cdi/summaries/16-4548.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 53-year-old female enrollee has requested reimbursement for the bilateral three dimensional digital breast tomosynthesis provided on 10/16/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. This patients breasts were described as heterogeneously dense. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 10/16/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 9da9bcd245b61b3f495d736a8b9d916b | ./data/processed/ca_cdi/summaries/16-4548.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 53-year-old female enrollee has requested reimbursement for the bilateral three dimensional digital breast tomosynthesis provided on 10/16/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that there is currently a lack of peer-reviewed literature that supports the use of three dimensional breast tomosynthesis compared to available techniques, especially in a patient without an increased risk of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in randomized clinical trials. All told, the digital breast tomosynthesis on 10/16/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 9da9bcd245b61b3f495d736a8b9d916b | ./data/processed/ca_cdi/summaries/16-4548.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 42-year-old male enrollee has requested authorization and coverage for anterior lumbar interbody fusion to lumbosacral vertebral segment L5 to S1 and two associated inpatient days. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient has a history of chronic low back pain and radicular manifestations in the left lower extremity. Anterior lumbar interbody fusion is associated with higher fusion rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine, including those with instability. There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone anterior lumbar interbody fusion has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. Per Mummaneni and colleagues, With regard to the type of interbody spacer used, frozen allograft is associated with lower pseudarthrosis rates compared with freeze-dried allograft; however, this was not associated with a difference in clinical outcome. The current medical evidence supports the requested services in this clinical setting. Therefore, anterior lumbar interbody fusion to lumbosacral vertebral segment L5 to S1 and two associated inpatient days are medically necessary for the treatment of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 86c032ea81fc28301691d07c5ace44b9 | ./data/processed/ca_cdi/summaries/19-6864.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting. According to 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 that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. The medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. All told, breast tomosynthesis performed on 7/13/15 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 466a6bb8d353a098aef760c2193b53e6 | ./data/processed/ca_cdi/summaries/16-4419.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the current medical evidence supports the services at issue in this clinical setting. Due to the tomographic nature of the technique, breast tomosynthesis allows radiologists to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. In this case, it was more advantageous for the patient to have her mammogram include breast tomosynthesis than having had it with two-dimensional imaging alone. Therefore, breast tomosynthesis performed on 7/13/15 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 466a6bb8d353a098aef760c2193b53e6 | ./data/processed/ca_cdi/summaries/16-4419.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. However, in this case, the patients presenting symptom was breast pain. Breast pain is rarely associated with breast cancer, especially without a recognizable mass. In addition, her breast density was described as containing scattered areas of fibroglandular elements. Her breasts were not particularly dense. Breast tomosynthesis has not been shown to provide significant increased value in this clinical setting. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 466a6bb8d353a098aef760c2193b53e6 | ./data/processed/ca_cdi/summaries/16-4419.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The parent of a 15-year-old female enrollee has requested authorization and coverage for Focalin XR 25mg, 1 capsule every morning. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees attention deficit disorder (ADD) without hyperactivity. The physician reviewer found in a study by Borgheini, brand name medications had a higher bioavailability than generic medication. This same study also indicated that illness recurred quite readily after brand was switched to generic. Desmarais and colleagues in a review article citing studies from 1974 through 2010 raise concern about the efficacy of generic drugs versus their brand equivalents, suggesting that amount of active ingredients in the generic was quite different than similarly dosed brand names. These studies indicate that use of generic medications may lead to higher dosing requirements and may lead to relapse of symptoms or need for more intensive services. Medical guidelines generally recommend change in medication after two to three failed medication trials. In this is a case, Adderall XR, Concerta and Metadate CD and Vyvanse were tried and failed in some significant way. While there may be other products on the market with similar ingredients, medical studies have shown that some individual patients may respond better to one product over another. Upon review of this patients submitted medical records, this appears to be one of those cases. Therefore, the requested Focalin XR is medically necessary for treatment of the patients medical condition.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | c15879534c6e5897256113d2c02853c9 | ./data/processed/ca_cdi/summaries/16-4532.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 56-year-old female enrollee has requested reimbursement for the hip surgery (CPT codes 29914 and 29915) provided on 6/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees right hip impingement syndrome. The physician reviewer found that surgical treatment of symptomatic femoroacetabular impingement aims to improve symptoms, potentially delay hip osteoarthritis, and prevent the need for a possible total hip arthroplasty. Hip arthroscopy and open surgical hip dislocations are the two most common surgical approaches used for this condition. The arthroscopic procedure avoids some of the complications of open surgery and results in over 75% positive results. Femoroacetabular impingement may be of the cam or pincer-type or it may be mixed. In this patients case, the femoroacetabular impingement was mixed, degenerative changes were mild, and conservative treatment failed to improve her condition, thus surgery was recommended. The patient met the surgical criteria for the procedure which included correction of the cam and pincer as well as repair of the labrum. Based upon a review of the medical records including the magnetic resonance imaging (MRI) scan and operative report, the hip surgery (CPT codes 29914 and 29915) provided on 6/17/16 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 8bdc53b9766d0b0efd3853a8d4ba76ae | ./data/processed/ca_cdi/summaries/18-6177.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 56-year-old female enrollee has requested reimbursement for the hip surgery (CPT codes 29914 and 29915) provided on 6/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees right hip impingement syndrome. The physician reviewer found that in the peer-reviewed medical literature, Hellman and colleagues reviewed five approaches for surgical management of femoroacetabular impingement syndrome, including arthroscopy. The authors reported that when nonsurgical treatment methods fail, surgical options were recommended, but there was no long-term outcome data to support one method over another. Harris and colleagues concluded that the outcomes of operative treatment of femoroacetabular impingement are significantly better than nonsurgical management. This patient presented with a three year history of hip pain that had severely worsened six months prior to initial examination. The pain interfered with her work duties and activities of daily living. Clinical examination findings were consistent with femoroacetabular impingement syndrome. She failed over six months of conservative treatment including activity modification, chiropractic care, ice, and anti-inflammatory medications. There were no significant degenerative findings of the right hip. Therefore, the right hip arthroscopy with femoroplasty and acetabuloplasty (CPT codes 29914 and 29915) performed on 6/17/16 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 8bdc53b9766d0b0efd3853a8d4ba76ae | ./data/processed/ca_cdi/summaries/18-6177.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 56-year-old female enrollee has requested reimbursement for the hip surgery (CPT codes 29914 and 29915) provided on 6/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees right hip impingement syndrome. The physician reviewer found that Femoroacetabular impingement is recognized as a common cause of hip pain resulting from abnormal contact between the proximal femur and acetabular rim. Abnormalities can be identified on either the femoral or acetabular side, but are most commonly seen on both sides. Harris and colleagues demonstrated that surgical treatment is effective and recommended in patients who fail to improve with routine conservative therapy. In this case, the patient is a physical trainer who performed activity modification and independent exercise, underwent chiropractic care, and was treated with nonsteroidal anti-inflammatory medications and opioid pain medications. The 4/23/16 magnetic resonance imaging (MRI) was interpreted as demonstrating moderate to high grade cartilage loss, but that appears to have been an overestimate based on the preoperative x-rays and operative findings documented in the surgical report. The 4/26/16 x-rays did not reveal substantial cartilage space narrowing. All told, the hip surgery (CPT codes 29914 and 29915) provided on 6/17/16 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 8bdc53b9766d0b0efd3853a8d4ba76ae | ./data/processed/ca_cdi/summaries/18-6177.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 42-year-old female enrollee has requested authorization and coverage for Trokendi XR. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees migraine headaches. The physician reviewer found that there is sufficient support in the medical literature and in the submitted documentation for the requested medication. Trokendi XR is an extended release version of topiramate. Its pharmacokinetic studies indicate smoother exposure, and less variation of blood levels compared to the immediate release formulation. Studies indicate better tolerability, fewer side effects, and better patient acceptance. Clinical notes in this case also indicate that the patients tolerability has been better at comparable doses. A review of topiramate studies in migraines treated with extended release topiramate support a clinically meaningful benefit of extended release topiramate versus immediate release topiramate in terms of significantly fewer cognitive effects, improved adherence, and overall better outcomes of migraine prophylaxis with topiramate. Based on the clinical notes, she has done better with Trokendi then the generic, immediate release. Trokendi XR is U.S. Food and Drug Administration approved and indicated for migraine prevention. While it has the same active ingredient as generic topiramate, it is not therapeutically equivalent as evidenced by studies as well as in this patient. All told, Trokendi XR is medically necessary for treatment of this patients medical condition.Therefore, 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. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 3fd9ee6cef8bab528b1b7f2573d793e1 | ./data/processed/ca_cdi/summaries/17-5023.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 63-year-old male who was diagnosed in 2015 with mild obstructive sleep apnea with an apnea-hypopnea index of 8 per hour. The patient failed oral appliance treatment. He was recently diagnosed with lung sarcoidosis. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. This patient was diagnosed with obstructive sleep apnea by a home sleep study in 2015. This type of testing can underestimate the severity of the patients disease. He failed oral appliance. The patient is symptomatic and has lung sarcoidosis, which may affect the accuracy of a new home sleep study. Per the records, CPT code 95811 is medically indicated to diagnose and treat this patient appropriately. Therefore, CPT 95811, split night sleep study, is medically necessary for the evaluation of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 2e88a10a7a17b8dcae572a01ba81c13a | ./data/processed/ca_cdi/summaries/20-7088.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 46-year-old female enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) with computer aided detection performed on 11/10/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollee, who has a history of left breast ductal carcinoma in situ. The physician reviewer found there is a lack of support for the services at issue in this clinical setting. Breast MRI has an important role in both screening and diagnostic settings. MRI studies of the breast are highly sensitive, but have a relatively low level of specificity. In some studies, the specificity of breast MRI has been reported to be as low as 37%. There is a lack of evidence to support the use of MRI as a surveillance tool rather than conventional mammography. Concerning DCIS, there is considerable literature which suggests that the term carcinoma should be dropped when describing these changes. Often, DCIS is characterized as stage 0, or a pre-cancerous condition. The National Comprehensive Cancer Network (NCCN) has recommended routine follow-up physical examinations and regular follow-up mammography for surveillance following a diagnosis of DCIS. The NCCN does not recommend follow-up surveillance MRI. In this case, there has been no submitted information which would warrant routine use of MRI for this patient. All told, breast MRI with computer aided detection performed on 11/10/15 was not medically indicated for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 62aa2449420151041233cd457b4af130 | ./data/processed/ca_cdi/summaries/17-4948.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 39-year-old female has requested reimbursement for Anser ADA testing performed on 6/25/15. 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 a lack of support for the services at issue in this clinical setting. There is insufficient evidence to support the use of Anser ADA testing. Studies performed thus far have included retrospective cohorts or have employed an observational design. There is a need for randomized controlled trials of tumor necrosis factor level and antibody driven care versus standard of care. Therefore, Anser ADA testing performed on 6/25/15 was not likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 7c41b321741a293eb23758e459fde94c | ./data/processed/ca_cdi/summaries/16-4471.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 39-year-old female has requested reimbursement for Anser ADA testing performed on 6/25/15. 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 not currently sufficient medical evidence to support the effectiveness of Anser ADA compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small and retrospective and/or observational in nature. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Therefore, Anser ADA testing performed on 6/25/15 was not likely to have been of greater benefit than other modalities for 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 7c41b321741a293eb23758e459fde94c | ./data/processed/ca_cdi/summaries/16-4471.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 39-year-old female has requested reimbursement for Anser ADA testing performed on 6/25/15. 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 this patient has been maintained on Humira but developed relapse of symptoms. Anser ADA testing measures the Humira blood level and detects antibodies to Humira. Patients with detectable levels and no antibodies will have to have a change in treatment management in order to control their disease, as the test implies an escape phenomenon to Humira. Patients with undetectable levels and antibodies are under-dosed and a higher dose will be needed to achieve remission and control of disease. Also, patients with a low level and detectable antibodies have a low drug level due to the development of antibodies. In this case, the patient responds to a higher dose and/or a higher frequency, or both. It is important for the treating provider to have a roadmap of the nature of the patients clinical course. There is sufficient support for Anser ADA testing in this patients case. 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 7c41b321741a293eb23758e459fde94c | ./data/processed/ca_cdi/summaries/16-4471.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 1
The patient is a 53-year-old female who had developed malignant melanoma on the skin of right medial thigh with a Breslows depth of approximately 0.4 mm. The DecisionDX-Melanoma gene assay performed on 9/15/17 revealed Class 1A molecular signature associated with a low risk of recurrence within five years. The patient has requested reimbursement for the genetic testing performed on 9/15/17, but the Health Insurer denied this request indicating that the services at issue were considered investigational for evaluation of the patients cutaneous melanoma. There is a lack of peer reviewed published studies as to this tests superior efficacy when compared to other standard modalities. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. DecisionDx-Melanoma assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as class 1, consistent with a low risk of metastasis, or class 2, suggestive of a high risk of metastasis. While the majority of clinical stage I patients will be disease free at five years, some stage I patients will develop advanced disease. According to the results of analysis of this patients melanoma performed with DecisionDx-Melanoma assay, the tumor was classified as class 1 with a low risk of near term within five years metastatic disease. In sum, while there is some support in the medical literature for the efficacy of the services at issue, genetic testing performed on 9/15/17 was not likely to have been of greater benefit than the available standard methods for the evaluation of patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 313b8704d2503e02d4f849f2114f9d4d | ./data/processed/ca_cdi/summaries/18-6361.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
The patient is a 53-year-old female who has been diagnosed with a melanoma on her thigh measuring 0.4 mm Breslow depth. Her provider sent her tissue for molecular genetic testing to help determine the risk of spread of the tumor. The patient has requested reimbursement for the genetic testing performed on 9/15/17. The Health Insurer denied this request for reimbursement and noted that the services at issue were considered investigational for the evaluation of this patients medical condition. The DecisionDx-Melanoma assay tests the tissue genetics of the melanoma and can stratify whether a melanoma is high risk for metastasis or not. The patients provider recommended her tissue be sent for a test called DecisionDX where the genes are examined for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some accuracy determining risk of metastasis in thin thickness melanomas like this patients; however, decision-making based on the results of the test is indeterminate at this time. The treatment of this patient would not change based on the results of the examination. Moreover, this test is not considered a routine standard of care and is not currently recommended by the National Comprehensive Cancer Network (NCCN) guidelines. There is not enough published data to support its routine use. Accordingly, the genetic testing performed on 9/15/17 was not likely to have been more effective than the available standard options for evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 313b8704d2503e02d4f849f2114f9d4d | ./data/processed/ca_cdi/summaries/18-6361.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
The patient is a 53-year-old female with history of melanoma. The provider ordered genetic testing to assess the metastatic risk of the patients 0.4 mm Breslow depth melanoma affecting the right medial thigh. The patient has requested reimbursement for the genetic testing performed on 9/15/17. The Health Insurer denied this request for reimbursement on the basis that the services at issue were considered investigational for the evaluation of this patients medical condition. The use of this type of genetic testing is not considered a standard of care in this clinical setting. The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting (Coit, et al). As such, the utilization of DecisionDx-Melanoma gene assay is not expected to affect the treatment or health outcome of this patients melanoma. In sum, the genetic testing performed on 9/15/17 was not likely to have been superior over the standard treatment options for the evaluation of this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 313b8704d2503e02d4f849f2114f9d4d | ./data/processed/ca_cdi/summaries/18-6361.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 35-year-old female enrollee has requested reimbursement for BRCA1, BRCA2 (breast cancer 1 and 2) (hereditary breast and ovarian cancer) gene analysis, full sequence analysis and common duplication/deletion variants in BRCA1 performed on 12/07/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation does not support the medical necessity of the services at issue. While the lifetime risk score completed by Myriad MyRisk was estimated to be 29.6%, higher than the 20% lifetime risk considered threshold for changes in management, this indicates that the patient should be considered for earlier or increased breast screening, not necessarily that genetic testing of BRCA1 and BRCA2 were indicated. Genetic testing for hereditary cancer predisposition syndromes are most useful in individuals who have a personal history of cancer or in those who have affected family members with known mutations. In this patients case, negative BRCA1 and BRCA2 testing did not reduce her risk, as the records do not document the cause of cancer in any of her family members, particularly in the paternal aunt, who is the only relative with cancer at a young age. The current medical evidence does not support the services at issue in this clinical setting. Therefore, BRCA1, BRCA2 (breast cancer 1 and 2) (hereditary breast and ovarian cancer) gene analysis, full sequence analysis and common duplication/deletion variants in BRCA1 performed on 12/07/18 were not medically necessary for the evaluation of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 2ec6f52007e30de1848463a50637f381 | ./data/processed/ca_cdi/summaries/19-6741.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 58-year-old male enrollee has requested authorization and coverage for Testim. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees low testosterone. The physician reviewer found that on the presented clinical records submitted for review, Testim is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patients testosterone levels are normal. There are no laboratory tests showing luteinizing hormone or follicle stimulation hormone levels. Furthermore, there is a lack of documentation demonstrating low bone mineral density, low libido or weight loss. Given the lack of support in the documentation provided, the request for Testim has not been established as 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. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 00b4c74af0d292986a486226ccb15d11 | ./data/processed/ca_cdi/summaries/18-6153.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The parent of a 16-year-old female enrollee has requested reimbursement for services at Provo Canyon School in Utah from 8/31/14 through 12/19/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. Outpatient treatment and least restrictive options are considered first lines of care as referenced by The American Academy of Child and Adolescent Psychiatry (Hales, et al). The standard of care for treatment of children and adolescents should be in the least restrictive setting as possible in order to maintain and foster natural supports (Winters, et al). It is further recommended that children should be treated in the setting that is least restrictive and disruptive to their lives. Inpatient or residential treatment is indicated only in emergencies or for children who have not responded to efforts at outpatient treatment. In a study by Barth and colleagues, children in intensive in-home therapy were more likely to live with family, make progress in school, not have trouble with the law, and have better placement permanence than youth who were treated in residential treatment facilities. In this patients case, she made significant progress regarding her behaviors and her ability to control her distress. By 8/1/14, her thoughts of self-harm decreased since her initial admission in May 2014. The improvement in her symptoms indicated that she could have been managed in a less restrictive setting. While she had continued symptoms of anxiety and periods of emotionality, she was not displaying any significant or severe behavioral problems during the disputed period. She was noted to be cooperative in therapy and was insightful into her need for treatment and her behaviors. The records indicate that the patient needed more treatment to further improve her social functioning, anxiety, family relationships, and self-harm thoughts. However, the submitted documentation indicates that this patient no longer needed the restrictiveness of a residential psychiatric treatment facility as she had stabilized enough over the previous three months of residential care to transition to a less restrictive setting by 8/31/14. The medical evidence support residential treatment when used for acute stabilization. However, there is a lack of evidenced based reviews to support residential treatment for long term care as in this patients case. All told, the services at Provo Canyon School in Utah from 8/31/14 through 12/19/14 were not medically necessary for 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 3ed141f1e3bd0aefc502be9776a26ef9 | ./data/processed/ca_cdi/summaries/17-4894.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The patient is a 40-year-old male with chronic left-sided low back pain. He has tried physical therapy as well as medications. The patient has requested authorization and coverage for arthrodesis sacroiliac joint, percutaneous or minimally invasive. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has localized pain to the sacroiliac joint. This pain has responded to anesthetic injection, indicating that the sacroiliac joint is the pain generator. The patient has failed reasonable nonsurgical treatments, and the current high-level evidence supports minimally invasive fusion to have superior outcomes to further conservative care. Therefore, arthrodesis sacroiliac joint, percutaneous or minimally invasive is medically necessary for the treatment of this patient.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 1e93ef218bd285d89833308f2e1069a3 | ./data/processed/ca_cdi/summaries/21-7372.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 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 physician reviewer found there is a paucity of scientific literature supporting a dose of Adderall XR above 60 mg. Doses above 60 mg have not been demonstrated to be more effective than lower and safer doses of Adderall. There are also cardiovascular concerns with doses above 60 mg. There is no substantial evidence suggesting that 90 mg of Adderall XR is more efficacious than 60 mg. There is also concern for abuse potential with doses higher than recommended as tolerance, psychological dependence, and social disability can occur if taken at higher than recommended doses. Given these findings, the requested Adderall XR 90 mg daily is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 94be501d5eabaa9efb96ae45219bc555 | ./data/processed/ca_cdi/summaries/17-6078.jsonl | Insurer Denial 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 94be501d5eabaa9efb96ae45219bc555 | ./data/processed/ca_cdi/summaries/17-6078.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
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 the provider reports that the patient has been stable for the extensive period of time of seven years on a regimen of Adderall XR 60 mg in the morning and 30 mg in the afternoon. The patient is noted to have no side effects and is sleeping well. This supports the efficacy of the requested medication at a daily dose of 90 mg. Therefore, the requested brand Adderall XR 90 mg daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication dosage is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 94be501d5eabaa9efb96ae45219bc555 | ./data/processed/ca_cdi/summaries/17-6078.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 70-year-old female enrollee has requested reimbursement for an intermittent limb compression device provided from 10/13/16 through 10/28/16. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees right knee pain. The physician reviewer found that the patient underwent arthroscopic surgery for osteoarthritis of the right knee including degenerative meniscal tears and chondromalacia on 10/13/16. There is no prior history of thromboembolism. The recent medical literature suggests that the incidence of symptomatic venous thromboembolism after arthroscopic knee surgery is very low and therefore the guidelines do not recommend intermittent pneumatic compression or pharmacotherapy postoperatively (Mauck, et al). The guidelines from the American College of Chest Physicians and American Academy of Orthopedic Surgeons agree that routine prophylaxis to prevent symptomatic venous thromboembolism is not needed for patients undergoing outpatient knee arthroscopy (Falck-Ytter, et al). For these reasons, the intermittent pneumatic compression provided from 10/13/16 through 10/28/16 was not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the device at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 308d3262dcaa443fe8270ca218017c59 | ./data/processed/ca_cdi/summaries/17-6049.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 63-year-old male enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees liver cancer. The physician reviewer found the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The most recent National Comprehensive Cancer Network (NCCN) guidelines for colon cancer state that In patients with a limited number of liver or lung metastases, radiotherapy can be considered in highly selected cases. For small liver lesions, it is well-established that SBRT yields high rates of control. In addition, radiation techniques other than SBRT will not likely allow adequate dose escalation to sufficiently treat the tumor or provide adequate normal tissue sparing. For this patient, with a lesion near the hilum radiofrequency ablation (RFA) is not an option as the tumor cannot be sufficiently heated as the vascular flow dissipates the heat, and there is a risk of vascular trauma such that RFA is contraindicated and conventional radiation is likely to be less efficacious. Therefore, SBRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 736a305c9d3fbdffd9ca795325977035 | ./data/processed/ca_cdi/summaries/15-4116.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 63-year-old male enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees liver cancer. The physician reviewer found SBRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a long history of oligometastatic disease from a diagnosis of colon cancer. The peer-reviewed literature demonstrates that aggressive local therapy in the form of stereotactic body radiation can be beneficial for patients with oligometastatic disease (Palma, et al; Hanna and Landau). In addition, the National Comprehensive Cancer Network (NCCN) guidelines state that SBRT can be utilized in the management of liver metastases from colon cancer. Therefore, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 736a305c9d3fbdffd9ca795325977035 | ./data/processed/ca_cdi/summaries/15-4116.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 63-year-old male enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees liver cancer. The physician reviewer found SBRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a single metastatic lesion in liver. SBRT has been used to treat primary liver cancer as well as metastatic lesions in liver. There are several clinical published studies to support SBRT for such clinical conditions (Lee, et al). Moreover, the provider documents that the patient is not a candidate for radiofrequency ablation as the lesion is close to vessels. For the reasons provided, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 736a305c9d3fbdffd9ca795325977035 | ./data/processed/ca_cdi/summaries/15-4116.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 37-year-old female enrollee has requested authorization and coverage for bronchoscopic thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is investigational for treatment of the enrollees persistent asthma. The physician reviewer found that based on the documentation provided, there is inadequate evidence for a diagnosis of asthma in this patient. There was no documentation provided to describe the onset of the patients symptoms and pulmonary function testing is normal and does not show evidence of obstruction or bronchodilator response. It would be expected that a patient with severe persistent asthma would demonstrate some abnormality on pulmonary function testing. There is also inadequate data on the patients history of exacerbations which is a prime consideration for bronchoscopic thermoplasty. Consideration should be given to alternate diagnoses such as inducible laryngeal obstruction, excessive dynamic airway collapse and reactive airways dysfunction syndrome for this patients symptoms. In the absence of documented asthma based on physical exam findings, clinical symptoms, exacerbation history, and objective lung function testing, the requested bronchoscopic thermoplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | ad32cd11b391a36c7e14bdb44d9cfdf9 | ./data/processed/ca_cdi/summaries/17-4799.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 37-year-old female enrollee has requested authorization and coverage for bronchoscopic thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is investigational for treatment of the enrollees persistent asthma. The physician reviewer found that currently, the three trials of bronchoscopic thermoplasty have demonstrated improved symptom control after the procedure was completed. The AIR trial examined 112 subjects with moderated to severe asthma and demonstrated improved control over the course of the one year follow-up (Cox, et al). The RISA study examined the safety of thermoplasty and found short-term worsening in symptoms, but evidence of improved long-term control of asthma (Pavord, et al). The authors found that the thermoplasty group had fewer exacerbations and improved quality of life when compared to the sham group. The AIR2 trial had 30% of the enrolled patients in the thermoplasty group on other controlling agents and fewer patients on oral corticosteroids (Castro, et al). Several years ago, two follow-up studies were performed establishing a long term improvement in asthma control over five years after the bronchoscopic thermoplasty was performed. While this patient has severe asthma, likely allergic, her elevated IgE is not being addressed. Thus, prior to initiating bronchoscopic thermoplasty, the patient may respond to treatment with omalizumab. Accordingly, the requested bronchoscopic thermoplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | ad32cd11b391a36c7e14bdb44d9cfdf9 | ./data/processed/ca_cdi/summaries/17-4799.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 37-year-old female enrollee has requested authorization and coverage for bronchoscopic thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is investigational for treatment of the enrollees persistent asthma. The physician reviewer found that Bronchial thermoplasty is a procedure that uses a bronchoscope probe to provide thermal energy to the smooth muscle of the airway. The tissue is heated to 65 degrees Centigrade. There are three bronchoscopic procedures. The first procedure treats the right lower lobe, the second treats the left lower lobe, and the third bronchoscopic procedure is for both upper lobes. The procedures are scheduled three weeks apart. In the medical literature, the therapeutic effect of sham placebo bronchial thermoplasty was similar to bronchial thermoplasty. Castro and colleagues reported that providing thermal energy to the airway had no beneficial effect in their study of 288 patients. This patients provider states the patient has a progressive decrease in the quality of life but there is a lack of documentation that the use bronchial thermoplasty would improve the long-term functional outcome of the patients condition. For these reasons, the requested bronchoscopic thermoplasty is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | ad32cd11b391a36c7e14bdb44d9cfdf9 | ./data/processed/ca_cdi/summaries/17-4799.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 58-year-old female enrollee has requested reimbursement for blepharoplasty of the upper eyelid performed on 12/07/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this patients case. The blepharoplasty was not medically necessary based on the lack of appropriate visual field information. The visual fields provided were threshold tests in grayscale format. In order to determine superior eyelid scotoma, a suprathreshold static visual field is required. The provided fields did not demonstrate absolute superior scotomas, and printed results were in grayscale representation only, rather than the numerical visual field test results. This is not a reliable or appropriate visual field test to demonstrate superior visual field loss due to eyelid obstruction. Therefore, upper eyelid blepharoplasty performed on 12/07/18 was not medically necessary for the treatment of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 59081e587e8708541d131b5c78d5a20f | ./data/processed/ca_cdi/summaries/19-6805.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 54-year-old female enrollee has requested authorization and coverage for Harvoni. 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 American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, AASLD/IDSA the guidelines state that high priority for treatment owing to high risk for complications includes patients with fibrosis of Metavir F2. This patient has a Metavir of F2; hence, treatment is indicated. Therefore, Harvoni should be approved as medically necessary based on national guidelines. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e0a07f80141e70e067383bf179f75b10 | ./data/processed/ca_cdi/summaries/15-4227.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 58-year-old female enrollee has requested reimbursement and prospective authorization and coverage for physical therapy services provided from 1/22/16 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 thoracic degenerative disc disease and facet dysfunction, lumbar foraminal and central stenosis. The physician reviewer found that although a multidisciplinary approach to spine pain including physical therapy may be beneficial, the goal of therapy is to transition to an independent home exercise program without continued dependence on supervised therapy. Based on the available records, the additional requested physical therapy is not supported as a specific and effective treatment for this patients medical condition. The documentation does not indicate that prior extensive physical therapy has resulted in significant objective increase in overall function. Moreover, the services provided from 1/22/16 forward do not need to be only under the supervision of a therapist. The patient has had extensive prior physical therapy and should be well versed in a home exercise program. The patients expected rehabilitation potential is not significant in relation to the extent and duration of the physical therapy services. The specialized skill of a qualified therapist is not required to establish, design and/or deliver a maintenance program to maintain the patients current condition or to prevent or slow further deterioration. All told, the physical therapy services provided from 1/22/16 forward were not and are not medically necessary for treatment of this patients medical condition. 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. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 76395f0758a0eacaff3db02b320de35f | ./data/processed/ca_cdi/summaries/17-4932.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 72-year-old male enrollee has requested reimbursement for brachytherapy performed on 7/5/17 through 7/31/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees basal and squamous cell cancer. The physician reviewer found that there is support in the medical literature for the services at issue. Radiation therapy is an option for the initial management of small, well defined, primary cutaneous squamous cell carcinomas. It is primarily reserved for older patients and patients who are not surgical candidates due long term side effects. According to the documentation provided, this patient meets the standard criteria. Brachytherapy is the standard of care for treating this patients primary cutaneous squamous cell carcinomas. In sum, the brachytherapy performed on 7/5/17 through 7/31/17 was medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated above, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 2d6f4a0febac566937cf216605ee48fa | ./data/processed/ca_cdi/summaries/18-6347.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 60-year-old female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) and nerve conduction velocity (NCV) studies provided on 9/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Hashimotos thyroiditis. The physician reviewer found that the Thyroid Trio testing comprises three different tests that are not routinely recommended by providers caring for patients with thyroid problems. There is a lack of medical literature supporting the utility of the MTHFR and NCV studies in this clinical setting. Further, the American Thyroid Association Task Force on Thyroid Hormone Replacement does not include the testing used in this case for evaluation of this patients medical condition. All told, the MTHFR and NCV studies performed on 9/22/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | d1c387e246be1caf10dcec120eda35ce | ./data/processed/ca_cdi/summaries/16-4719.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 60-year-old female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) and nerve conduction velocity (NCV) studies provided on 9/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Hashimotos thyroiditis. The physician reviewer found that Crone and Krarup noted diagnostic considerations for use of NCV are based on a flow chart classifying neuropathies into eight categories based on mode of onset, distribution, and electrophysiological findings, and the electrophysiological characteristics in each type of neuropathy are discussed. NCV is useful for evaluation of neurologic deficits but is not recommended in the absence of neurologic symptoms or physical findings. The medical records do not indicate physical exam findings of focal neurologic deficit or symptoms in support of NCV testing. In addition, NCV testing is not supported for evaluation of Hashimotos thyroiditis. As there are no neurologic symptoms or findings reported, NCV studies were not appropriate for evaluation of this patients medical condition. There is one publication in regard to MTHFR use for association with Hashimotos disease, but there is a lack of support for clinical application for individual clinical determination. Arakawa and colleagues found that some data suggests that a certain genotype correlates with DNA hypomethylation and with the intractability of goiter, and another genotype may correlate with the severity of Hashimotos disease. However, the authors noted that additional studies are needed to determine clinical correlation. Consistent with these findings, the MTHFR and NCV studies provided on 9/22/15 were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | d1c387e246be1caf10dcec120eda35ce | ./data/processed/ca_cdi/summaries/16-4719.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 60-year-old female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) and nerve conduction velocity (NCV) studies provided on 9/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Hashimotos thyroiditis. The physician reviewer found that based on current medical guidelines, the MTHFR and NCV testing performed on 9/22/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Neither of these tests are integral to the management and treatment of the patients hypothyroidism. While patients with hypothyroidism may experience neuropathy and muscle complaints, a NCV test is generally not indicated to diagnose or treat this condition. MTHFR testing has no role in the treatment of patients with hypothyroidism and Hashimotos thyroiditis. Recent data indicates that there is a lack of evidence for this type of testing in this clinical setting. 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | d1c387e246be1caf10dcec120eda35ce | ./data/processed/ca_cdi/summaries/16-4719.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 37-year-old female enrollee has requested authorization and coverage for escitalopram three tablets 20 mg daily. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the United States Food and Drug Administration (FDA) provides medication dose recommendations based on scientific data. The interpretation and application of these recommendations falls upon providers working directly with the patient population. This process allows for consideration of additional factors, such as provider experience, emerging treatment trends and clinical issues unique to individual cases, in the delivery of evidence-based, patient-centric care. As such, systematic medication titration is a core element of the art of medical practice and a key component to patient-centered care. Escitalopram is a potent and highly selective serotonin reuptake inhibitor (SSRI) that acts by binding directly to the serotonin transporter. Like other SSRI medications, escitalopram is a trusted intervention in the treatment armamentarium for those suffering from OCD. Providers have long recognized that the treatment of OCD often requires supra-therapeutic SSRI dosing. This practice is supported by the American Psychiatric Association (APA) clinical practice guideline for OCD which supports the occasionally prescribed maximum dose of escitalopram is 60 mg per day. Considering the medical records, community standards, endorsement from the APA and the peer-reviewed literature base, escitalopram 60 mg daily represents a safe, appropriate treatment consistent with good medical practice. The requested medication is reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the requested escitalopram three tablets 20 mg daily are medically necessary for treatment of the patients behavioral health condition. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 21571a912b9c1a08a67c655019337c0a | ./data/processed/ca_cdi/summaries/16-4346.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 28-year-old male enrollee has requested reimbursement for residential rehabilitation level of care services provided from 8/4/16 through 8/19/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse. The physician reviewer found that this patients records did not include any psychiatric or medical admitting evaluations. In addition, the patient did not present with any significant post-acute withdrawal symptoms. The patient was not a danger to himself or to others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant RTC level of care. He was medically and psychiatrically stable. He was motivated, insightful, and appeared to be working the program. He reported having had a multitude of prior treatments, with the ability to maintain abstinence for a prolonged period of time. Relapse risk is inherent among this population but is not alone an adequate reason to keep a patient at a higher level of care in the absence of unstable psychiatric illness or the potential for harm to self or others. Given the recidivistic nature of his illness with multiple relapses and subsequent treatments, he had the groundwork of relapse prevention education. His difficulties with abuse and relapse were chronic in nature and did not require 24-hour monitoring at the RTC level of care in the absence of unstable medical or psychiatric conditions. He could have safely been treated in a less restrictive level of care. Thus, the RTC rehabilitation level of care services provided from 8/4/16 through 8/19/16 were not medically necessary for treatment of this patients polysubstance abuse. 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | ff451bf9fcf513535125d4a12f67913b | ./data/processed/ca_cdi/summaries/16-4705.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The patient is a 22-year-old male who presented at age 19 with chest pain. The patient has requested reimbursement for the PET scan performed on 4/21/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that sarcomas of the heart are exceedingly rare tumors. Most cardiac tumors are benign, and of those that are malignant, the most common are angiomyosarcomas and rhabdomyosarcomas. Of the very rare cardiac sarcomas, synovial sarcomas account for only a tiny percentage. Hence, there is a lack of literature that has evaluated the efficacy of follow-up PET/CT scanning. In this patientas case, considering the high-grade nature of the tumor, as well as the size and presence of necrosis when the tumor was first discovered, there is a high likelihood of recurrence. Information was not submitted concerning whether the initial tumor resection had clean margins. The patient has continued on chemotherapy in spite of no evidence of metastasis or residual tumor. It is unclear what markers are being followed, other than a prophylactic suspicion of recurrence. Sarcomas most commonly recur locally, although they can metastasize (most commonly) to the lungs. One prognostic sign of a likely spread of tumor is tumor necrosis, as was noted in this patient. In order to effectively screen this high risk (and young) patient with CT scanning, one would have to do multiple scans to cover the entire body. Considering the lack of pertinent research and considering the highly aggressive tumor and the fact that the patient continues on chemotherapy, it is medically appropriate to continue the current regimen with regular MRI studies and PET/CT scans. This is especially valuable considering that the patient has a good set of baseline studies. There is sufficient support for the services at issue in this clinical setting. Therefore, the PET scan performed on 4/21/20 was medically necessary for the evaluation of this patient.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 364d2d1359d58575c0d63d5583692ff4 | ./data/processed/ca_cdi/summaries/20-7157.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 59-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/26/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her examination been done with two-dimensional imaging alone. 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 974c70c5ca301d2c88b77d3b982def13 | ./data/processed/ca_cdi/summaries/17-4878.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 59-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/26/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found there is sufficient support for 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. In sum, breast tomosynthesis performed on 9/26/16 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 974c70c5ca301d2c88b77d3b982def13 | ./data/processed/ca_cdi/summaries/17-4878.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 59-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/26/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. The medical literature supports the service at issue in this patients case. The study by Mansour and colleagues demonstrated that screening sensitivity of full field digital mammography was increased from 60% to 94.5%, and specificity increased from 20.7% to 74% when digital breast tomosynthesis was applied. Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings. Digital breast tomosynthesis allowed unnecessary biopsy to be avoided in 37.3% of patients. Thus, breast tomosynthesis performed on 9/26/16 was likely to have been more effective than other modalities for evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 974c70c5ca301d2c88b77d3b982def13 | ./data/processed/ca_cdi/summaries/17-4878.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 46-year-old female enrollee has requested reimbursement for CPT code 84999 performed on 1/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the prognosis for cutaneous melanoma has classically been determined by applying the staging spelled out by Balch. Mitotic index has also been thought to add a bit more to these statistics. By Balch staging, this melanoma would be classified as a T1a (stage 1A), with an expected ten-year survival of at least 88%. DecisionDx is a study of 31 genes in an individuals melanoma cells. It then classifies that melanoma as either Class 1 (with a 90-92% disease-free survival at five years), or Class 2 (with a 48-77% five-year disease-free survival). Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx classification, in patients who had undergone sentinel node biopsy. However, it is not clear how the five-year DecisionDx data compares to the ten-year Balch data, and, most importantly, whether it can be used additionally to make clinical decisions. This is especially true in this patient with an excellent prognosis. At this time, the superior effectiveness of CPT code 84999 performed on 1/12/17 has not been established. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | c639b13d5ad92baae56b8b3728a04893 | ./data/processed/ca_cdi/summaries/17-6084.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 46-year-old female enrollee has requested reimbursement for CPT code 84999 performed on 1/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the DecisionDx-Melanoma testing has been developed in patients with stage I and II cutaneous melanoma. However, 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 according to published data available. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. In sum, CPT code 84999 performed on 1/12/17 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | c639b13d5ad92baae56b8b3728a04893 | ./data/processed/ca_cdi/summaries/17-6084.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 46-year-old female enrollee has requested reimbursement for CPT code 84999 performed on 1/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, CPT code 84999 performed on 1/12/17 was not likely to have been more efficacious than other available 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | c639b13d5ad92baae56b8b3728a04893 | ./data/processed/ca_cdi/summaries/17-6084.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
The parent of a one-year-old male enrollee has requested reimbursement for inpatient hospital level of care provided on 3/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the patient was a five-month-old ex-premature infant who was approximately 44 weeks post conceptual age at the time that he presented for apnea and cyanosis associated with vomiting for which he was treated with back blows by his mother. The apneic episode resolved by the time of presentation to the hospital and he appeared to be healthy when evaluated by the provider. He was admitted for observation and cardiopulmonary monitoring. He was diagnosed with an apparent life threatening event (ALTE) due to gastroesophageal reflux disease (GERD). Other than monitoring, he received a suppository to treat constipation. He had no further apnea or cyanosis in the hospital. He tolerated oral intake without emesis. He remained well appearing and had no signs of acute illness. The medical literature supports hospitalization for observation for cardiopulmonary monitoring for 23 hours after an ALTE in the majority of infants (Fu and Moon; McGovern and Smith). However, certain individuals can be discharged from the emergency department without hospitalization (Kahn and European Society for the Study and Prevention of Infant Death). Given that the patient was well-appearing at the time of presentation, had no further events during observation in the hospital, did not require specific interventions or extensive evaluation beyond observation, and was discharged home on the same day of admission, he met criteria for observation but not admission. Based upon the information provided and reviewed and the medical literature reviewed, the inpatient hospital level of care provided on 3/31/16 was not medically necessary for treatment of the patients medical condition. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | c0107286d37ed2df960059de77b7a591 | ./data/processed/ca_cdi/summaries/17-4892.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 56-year-old female has requested reimbursement for percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of urinary frequency and urgency. The physician reviewer found that percutaneous tibial nerve stimulation may have a role in reducing uninhibited bladder contractions when first-line behavior modification and second-line medical therapy have failed to resolve symptoms of overactive bladder. In this patients case, there is also the complexity of past interventions, ongoing neuropathic issues, and diabetes increasing the risk of urinary tract infections. It is not standard of care to proceed with percutaneous tibial nerve stimulation prior to exhausting standard first-line behavior modification and second-line medical therapy. Percutaneous tibial nerve stimulation has not be shown to be more effective than these treatment approaches per the current evidence. Therefore, percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18 was not likely to have been of greater benefit than other available 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 30837cf5f4af5633aa9cfd941e9f26db | ./data/processed/ca_cdi/summaries/18-6495.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 56-year-old female has requested reimbursement for percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of urinary frequency and urgency. The physician reviewer found that there is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of percutaneous tibial nerve stimulation in patients with urinary urgency and frequency. However, most trials have a small number of patients with short-term follow-up. American Urological Association (AUA) guidelines recommend that clinicians should offer behavioral therapies, such as bladder training, bladder control strategies, pelvic floor muscle training and fluid management, as first-line therapy to all patients with overactive bladder. Behavioral therapies may be combined with pharmacologic management. Clinicians should offer oral antimuscarinics or oral 3-adrenoceptor agonists as second-line therapy. If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a 3-adrenoceptor agonist may be tried. Patients who are refractory to behavioral and pharmacologic therapy should be evaluated by an appropriate specialist if they desire additional therapy. The guidelines rate percutaneous tibial nerve stimulation as a third-line therapy. Botox injection is a standard third-line therapy which is graded better. The use of percutaneous tibial nerve stimulation has not been proven to be superior to other alternatives. In this case, the records do not document that the patient had a complete trial and failure of first-line and second-line therapy. The documentation does not support prior failure of behavior modification. She was prescribed low dose Toviaz, the response to which is unknown. The first intervention would be dose escalation if she had no response to low dose Toviaz. In sum, percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18 was not likely to have been superior over 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 30837cf5f4af5633aa9cfd941e9f26db | ./data/processed/ca_cdi/summaries/18-6495.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 56-year-old female has requested reimbursement for percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of urinary frequency and urgency. The physician reviewer found that percutaneous tibial nerve stimulation is considered to be an appropriate third-line salvage therapy for patient with intractable irritative lower urinary tract symptoms, including frequency and urgency incontinence. This patient did not have any urodynamic findings suggestive of overactive bladder. It appears that the patient was started on antimuscarinic therapy simultaneously with percutaneous tibial nerve stimulation. It would have been prudent for this patient to assess the outcome of antimuscarinic therapy prior to therapy with percutaneous tibial nerve stimulation. Thus, percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18 was not likely to have been more effective than other available treatment modalities. 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 30837cf5f4af5633aa9cfd941e9f26db | ./data/processed/ca_cdi/summaries/18-6495.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 27-year-old male enrollee has requested reimbursement for laboratory services (81243, 88230, 88262, 88289) provided on 10/19/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Per the records, the laboratory services in dispute are 88230, tissue culture for non-neoplastic disorders, lymphocyte, 88262, chromosome analysis, count 15-20 cells, two karyotypes, with banding, 88289, chromosome analysis, additional high resolution study, and 81243, fragile X (FMR1). Codes 88230, 88262 and 88289 can be grouped together, as the tissue culture is needed for chromosome analysis. In this patients case, it is unclear why the provider ordered both standard chromosome analysis and high resolution chromosome analysis, but neither were indicated. The providers notes state that this was ordered due to the patients sisters infertility and his mothers miscarriages. Either of these would be indications for chromosome analysis in the affected individual, but are not indications for analysis in this patient. With regards to 81243, the notes indicate that this was ordered due to a history of anxiety, depression, and obsessive-compulsive disorder in the patient, family history of autistic-like behaviors in the patients brother, and family history of psychiatric illness. This testing was not indicated. Fragile X is a common cause of significant intellectual disability and autism spectrum disorders, not reported in this patient (or his brother with autistic-like behaviors but high intelligence). Males with fragile X will have significant developmental concerns, which this patient does not have. Psychiatric illness alone is not caused by fragile X full mutations or pre-mutations. While his sisters infertility may be an indication for testing her if she has premature ovarian failure, testing this patient was not indicated. Therefore, laboratory services (81243, 88230, 88262 and 88289) provided on 10/19/18 were not medically necessary for the evaluation of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | bbe6762ee5fded7843f25dff3cba994c | ./data/processed/ca_cdi/summaries/19-6652.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 57-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine without contrast. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollees bilateral upper extremity pain and numbness. The physician reviewer found that the American College of Radiology (ACR) criteria recommends a plain x-ray for evaluated of patients with chronic neck pain. The ACR criteria suggest that for patients with radiographic evidence of degenerative changes and positive neurologic symptoms, the most appropriate test is an MRI of the cervical spine. This patients numbness and diminished reflexes are considered neurologic signs. Although this patients records do not document conservative therapy in addition to chiropractic care, the provider noted concern that continuing chiropractic manipulation may cause further damage without properly ruling out a significant herniation or stenosis. For these reasons, the requested MRI of the cervical spine without contrast is medically necessary for evaluation of this patients chronic neck pain. Based on the foregoing discussion, the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | bc3ea0cffdbfb884f95a9da2d371e5bc | ./data/processed/ca_cdi/summaries/18-6396.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 44-year-old female enrollee has requested reimbursement for doxycycline capsules delayed release 40 mg received on 5/22/18. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollee, who has a history of hypersensitivity reaction affecting the periocular area. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue. The records document a hypersensitivity reaction affecting the periocular area. Per the Health Insurer, the medication at issue cannot be approved unless the patient carries a diagnosis of rosacea and has already failed a one-month course of immediate-release 50 mg doxycycline. The medication at issue, doxycycline capsules delayed release 40 mg, is not considered to be superior or more efficacious than the preferred, generic immediate-release formula of doxycycline 50 mg. In fact, given the degree of inflammation, higher doses of doxycycline would be preferred for treatment of this eruption. Thus, doxycycline capsules delayed release 40 mg received on 5/22/18 were not medically necessary for the treatment of this patient. Therefore, the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | fff08029a9a89a0463e3c714848074c0 | ./data/processed/ca_cdi/summaries/18-6461.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 46-year-old female enrollee has requested authorization and coverage for Duavee 0.45-20 mg tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who is status post hysterectomy. The physician reviewer found that in this patients case, her menopausal symptoms included occasional hot flashes and vaginal dryness. There is no mention of other management options, including whether the patient has tried any other medicinal (hormonal or non-hormonal) and nonmedicinal forms of therapy and what the response to that therapy was, other than a prescription for Duavee. The benefit of Duavee is that it is selectively designed and marketed as a hormone replacement therapy that is more protective of the endometrium of the uterus than other progestins that are coupled with estrogens. This is not an issue for this patient. As she is status post hysterectomy, this patient does not need protection of her uterine endometrium. In this case, there are other reasonable estrogen only treatment options that would be more prudent for this patient. If the risks associated with estrogens and their potential relationship to breast/reproductive cancers is driving management, then the use of non-hormonal management, such as Paxil, may be a better option. The medical evidence does not support the requested medication in this patients case. Thus, Duavee 0.45-20 mg tablets are 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. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | d20c6189fab152e495c86d81c0246db2 | ./data/processed/ca_cdi/summaries/18-6384.jsonl | Insurer Denial Upheld | Medical Necessity |
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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 80ce20c2a301c2584696364c22f1656b | ./data/processed/ca_cdi/summaries/16-4366.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
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 the requested services are not likely to be more effective for this patient than other available options. Based on an assessment of the peer reviewed literature, the superior benefit of PFO closure versus medical therapy has not been established in cases such as in this clinical setting. The RESPECT trial did demonstrate superiority of PFO closure in patients assigned to the Amplatzer PFO occluder in comparison to guideline directed medical therapy with one or more antiplatelet agents or warfarin (Carroll, et al). However, no significant benefit in the primary intent to treat analysis was documented. In sum, the requested percutaneous transcatheter closure of atrial septal defect is not likely to be more beneficial for treatment of the patients medical condition than any other modalities.Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 80ce20c2a301c2584696364c22f1656b | ./data/processed/ca_cdi/summaries/16-4366.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
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 the request for closure of PFO is not likely to be more effective for this patient than other available options. Studies to date have not shown a clear benefit of transcatheter closure of PFO compared to standard medical therapy. Observational studies from a single institution, non-randomized, suggest some benefit (Inglessis, et al). In sum, there is a lack of sufficient data to support the request for percutaneous transcatheter closure of atrial septal defect for this patient at this patient at this time. Based upon the information set forth above, the services at issue 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 80ce20c2a301c2584696364c22f1656b | ./data/processed/ca_cdi/summaries/16-4366.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
The parent of a seven-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavioral analysis (ABA) therapy, in excess of 35 hours per week provided from 5/10/16 through 11/8/16. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism spectrum disorder. The physician reviewer found in this clinical setting, ABA therapy in excess of 35 hours per week provided from 5/10/16 through 11/8/16 was and is medically necessary for treatment of the patients medical condition. ABA therapy is medically indicated for children diagnosed with autism. The review by Reichow and colleagues shows that ABA started at a younger age provides improvements in cognitive skills, adaptive skills and language skills. In this case, the patient has received ABA therapy since his diagnosis in 2014. ABA therapy has been effective for him, however he continues to have self-injurious behaviors that include tapping/hitting, elopement and tantrum. Therefore, ABA therapy in excess of 35 hours per week were and are medically necessary for treatment of the patients medical condition. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 473103ae9aa18af4e8702b0c60011c0f | ./data/processed/ca_cdi/summaries/16-4682.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 26-year-old female enrollee has requested reimbursement for mental health partial hospitalization provided from 1/23/19 through 1/25/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. With regards to risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. In terms of functional status, the records support a score of 2 due to an overall good functional level with appropriate activities of daily living. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability, no chronic medical issues and no active substance use. In terms of level of stress of the recovery environment, the records support a score of 2 due to no mention of a stressful recovery environment. With regards to level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. In terms of treatment and recovery history, the records support a score of 2 due to success in the treatment program with a good level of cooperation and stabilization of symptoms. With regards to engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Therefore, the patient has a composite score of 13. This score correlates with low intensity community-based services. In sum, this patients presentation did not meet criteria for partial hospitalization program level of care during the disputed timeframe. Thus, mental health partial hospitalization services provided from 1/23/19 through 1/25/19 were not medically necessary for the treatment of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | b126a76c97c9ebc3bd4c2207b13076c5 | ./data/processed/ca_cdi/summaries/19-6758.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
An 18-year-old female enrollee has requested reimbursement for residential psychiatric treatment from 11/16/15 through 7/30/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. On initial evaluation, the patient was noted to have mood lability, anhedonia, passive suicidal ideation, impulsive behaviors, and poor relationships with peers and family. During admission to the residential facility, the patient was documented as being grandiose at times, irritable, suspicious of others, anhedonic, and guarded. She was not consistent with completing her activities of daily living and struggled with school assignments. She had difficulty with interacting with peers and would display oppositional behavior towards staff. She also had some difficulties tolerating medications. Aripiprazole was documented as causing confusion and spaciness. This medication was discontinued on 2/17/16 but subsequent progress notes indicated that the patient continued to struggle with her mood. From 5/19/16 through 5/22/16, the patient was documented as having a manic episode triggered by medication changes. During this manic episode, the patient also reported hallucinations and delusions and staff had difficulty managing her behavior. She was started on quetiapine and benztropine. She complained of blurry vision and her dose of quetiapine was lowered. On 7/18/16, the patient was documented as having continued irritability and dose of quetiapine was increased. The record noted that the patients medications were adjusted up until the time of discharge. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP). The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on the patients clinical history and documentation as outlined above, the patient met CASII criteria for 24 hour psychiatric monitoring during the disputed dates. The patients clinical status, in addition to current medical literature, support the treatment she received at the residential level of care. Accordingly, residential psychiatric treatment from 11/16/15 through 7/30/16 were medically necessary for the treatment of this patients medical condition. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | dc8984acfef80a133c80df7b7c5f4980 | ./data/processed/ca_cdi/summaries/18-6241.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 30-year-old male enrollee has requested reimbursement for assistant-at-surgery services for surgery (64999-AS) performed on 1/09/19. 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 most surgical procedures, especially major procedures, require an assistant. There were three descriptive codes listed in the operative report, and only the bronchoscopy could be completed solely by the primary surgeon. The robotic-assisted rib resection and neurolysis required coordinated teamwork to facilitate a safe and adequately exposed surgical field. When the surgeon is at the console, the assistant controls instrument placement and suction retraction. Similarly, when part of the procedure is open, the assistant retracts and provides access to prevent injury to adjacent structures. When re-docked and the neurolysis is completed by freeing the strictured vein, the assistant provides counter-tension, once again protecting other vascular structures and brachial plexus from injury. This patient underwent a major thoracic procedure with a high incidence of neurovascular complications. The current medical evidence supports the services at issue in this clinical setting. Therefore, assistant-at-surgery services for surgery (64999-AS) performed on 1/09/19 were medically necessary for the treatment of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | ec4b58087ed8cc237ee26bc86c5599d1 | ./data/processed/ca_cdi/summaries/19-6827.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 60-year-old female enrollee has requested reimbursement for collagen crosslinks laboratory tests performed on 1/2/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that osteoporosis is a condition of thinning of the bones which leads to increased risk of fracture. It is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by dual-energy x-ray absorptiometry. Bone mineral density (BMD) assessment, via a bone density test, is still the criterion standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to anti-resorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover (proteins and peptides, referred to as biochemical bone markers, that are released as a consequence of the physiological action of osteoblasts and osteoclasts) 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. These tests may also assist in identifying individuals with elevated bone resorption, who have osteoporosis in whom response to treatment is being monitored. 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 40cd53819de910a49ab7428329bd1f08 | ./data/processed/ca_cdi/summaries/16-4596.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 60-year-old female enrollee has requested reimbursement for collagen crosslinks laboratory tests performed on 1/2/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that biochemical markers of bone remodeling or serum or urinary collagen crosslinks tests are useful in certain situations to monitor efficacy and compliance with therapies for osteoporosis. However, this is not yet standard of care in the medical community, though they have a role in certain clinical situations. In this patients case, the submitted records do not indicate that these tests at issue were superior to available standard therapies for evaluation and treatment of the patients osteoporosis. 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 40cd53819de910a49ab7428329bd1f08 | ./data/processed/ca_cdi/summaries/16-4596.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 60-year-old female enrollee has requested reimbursement for collagen crosslinks laboratory tests performed on 1/2/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that according to the Clinicians Guide to Prevention and Treatment of Osteoporosis, biochemical markers of bone turnover may predict risk of fracture independently of bone density in untreated patients, predict rapidity of bone loss in untreated patients, and help determine adequacy of patient compliance and persistence with osteoporosis therapy. These statements are also supported by Burch and colleagues who performed a review regarding the use of bone turnover markers for monitoring the response to osteoporosis treatment. In this case, identifying baseline and subsequently monitoring markers of bone turnover to assist with best therapy options for the patient is medically appropriate and in line with sound medical practice. The requesting provider indicated that these tests were ordered to monitor compliance and response to anti-resorptive therapy. All told, these tests were likely to be more efficacious to guide the therapy for 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 40cd53819de910a49ab7428329bd1f08 | ./data/processed/ca_cdi/summaries/16-4596.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The patient is a 35-year-old female who is pregnant. The patient has requested authorization and coverage for Makena injection (hydroxyprogesterone caproate 10 mg). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that the literature supports the use of progesterone treatment to decrease the risk of preterm delivery in a patient who has a history of preterm birth. Research has shown that a prior spontaneous preterm birth is a risk factor for a subsequent spontaneous preterm birth, whether the initial preterm delivery was a singleton or a twin pregnancy. Although no study has specifically evaluated whether progesterone supplementation decreases the risk of a preterm birth of a singleton after a previous spontaneous preterm birth of twins, it is appropriate for providers to recommend this therapy. There is a theoretical benefit given available data. This provider is practicing within current standard of care, and progesterone therapy is appropriate in this clinical setting. Therefore, Makena injection (hydroxyprogesterone caproate 10 mg) is medically necessary for the treatment of this patient.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | d40508f1a2e2b6b681bb09df0c04abb3 | ./data/processed/ca_cdi/summaries/21-7240.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 60-year-old male enrollee has requested authorization and coverage for 18F-NaF positron emission tomography/computed tomography (PET/CT) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that based upon the recommendations of the National Oncologic PET Registry, the Centers for Medicare and Medicaid Services (CMS) revised its guidelines concerning coverage for PET scans in patients with solid tumors allowing up to three scans in each patient for diagnosis, staging and surveillance. While the use of this compound has proven to be of use in prostate cancer, the re-approval of 18F-NaF as a pharmaceutical has proven of greater benefit to patients with rising PSA levels where bone metastases are possible. The reason is the proven marked increased sensitivity of the technique compared to standard technetium bone scans in the detection and localization of skeletal metastatic deposits. In this patient with a rising PSA after radical prostatectomy, the possibility of subtle skeletal metastatic disease is possible and the requested 18F-NaF PET/CT scan is the most sensitive means with which to evaluate this patient. Based upon the information set forth above, I have determined the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 44f63bc9fc0f5e8a4771292cf815ec6a | ./data/processed/ca_cdi/summaries/15-4165.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 60-year-old male enrollee has requested authorization and coverage for 18F-NaF positron emission tomography/computed tomography (PET/CT) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that in the medical literature, Jadvar and colleagues reported that in patients with relapsed prostate cancer, 18F-NaF PET/CT is useful in the detection of occult osseous metastases, whereas the yield of 18F-FDG PET/CT is relatively limited. Poulsen and colleagues found that 18F-NaF PET/CT were superior to whole body scintigraphy with regard to detection of prostate cancer bone metastases within the spine. Thus, the literature does support 18F-NaF PET/CT to be superior to bone scan with regards to detection of prostate cancer bone metastases within the spine. Further, the requested 18F-NaF PET/CT is the most reliable tool when there is high index of suspicion for osseous metastases. Consistent with this support, the requested 18F-NaF PET/CT scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 44f63bc9fc0f5e8a4771292cf815ec6a | ./data/processed/ca_cdi/summaries/15-4165.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 60-year-old male enrollee has requested authorization and coverage for 18F-NaF positron emission tomography/computed tomography (PET/CT) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that the patient does not meet the current guidelines for the requested 18F-NaF PET/CT scan at this time. The National Comprehensive Cancer Network (NCCN) guidelines indicate that although sodium fluoride PET/CT may indeed be a promising technique in the re-staging of prostate cancer, the peer-reviewed medical literature and standards of care do not support the routine use of this study in this clinical setting. All told, the requested 18F-NaF PET/CT scan 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, I have determined the requested diagnostic procedure 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 44f63bc9fc0f5e8a4771292cf815ec6a | ./data/processed/ca_cdi/summaries/15-4165.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 55-year-old male enrollee has requested reimbursement for durable medical equipment (special stockings, Sock Aid Nova and stocking donners) provided on 8/2/16. The Health Insurer has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollees lymphedema of both lower extremities. The physician reviewer found that the durable medical equipment (special stockings, Sock Aid Nova and stocking donners) provided on 8/2/16 has been established as medically necessary for treatment of the patients medical condition. The patient presents with limb threatening lymphedema and venous stasis hypertension. This condition has caused ulcerations and cellulitis in the past. Prescription strength compression socks are the standard of care for patients with severely swollen lower extremities including, venous stasis hypertension, and lymphedema. These devices allow for mechanical compression of the lower extremity, facilitating movement of the fluid from the lower extremity proximal for distribution and resorption. This will in turn reduce the patients chance of ulceration, possible cellulitis, and possible further other complications. The compression socks along with the device to pull on the compression socks are medically necessary. The stocking donner is important as socks are difficult for people to place on themselves. It is an important part of the compliance of utilizing compression socks. Thus, the equipment at issue was medically necessary for the patients medical condition. Therefore, the equipment at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 5b3ca308fe22908010617ea5ab40849a | ./data/processed/ca_cdi/summaries/17-4846.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 59-year-old female enrollee has requested authorization and coverage for an insulin pump. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees diabetes. The physician reviewer found that insulin pump therapy is a technological advancement that has been developed to help patients manage type 1 diabetes. Insulin pump therapy is associated with psychosocial benefits and improved biomedical outcomes (Reidy, et al). Advantages of insulin pump therapy over multiple daily injections of insulin include better adherence, more accurate dosing, greater lifestyle flexibility, control of the dawn phenomenon without induction of nocturnal hypoglycemia, and the ability to suspend or temporarily reduce basal insulin to compensate for increased physical activity (Millstein, et al). While this patient has been able to manage her diabetes via insulin pump therapy, her current pump is no longer functioning. The patient requires a replacement pump in order to optimize her glycemic control. Accordingly, the requested insulin pump is medically necessary for treatment of this patients type 1 diabetes. Based on the foregoing discussion, the requested device is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | beda7f51c23f8434f8c984f933658ae6 | ./data/processed/ca_cdi/summaries/18-6419.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 47-year-old female with a history of bed confinement with upper and lower extremity weakness and contractures with pain that prevents movement. On 11/30/16, the enrollee was transferred from Kindred Los Angeles Hospital to Cedars-Sinai Medical Center for follow-up appointment for cerebral arteriovenous shunt. The enrollee was monitored en route. The patient has requested reimbursement for the non-emergency ambulance service provided on 11/30/16. The Health Insurer has denied this request indicating that the service at issue was not medically necessary. This patients records do not include any clinical justification for the ambulance service provided on 11/30/16. The patient is bedridden but does not require medical transportation. The documentation suggests that the use of the ambulance was provided for patient convenience. Accordingly, the non-emergency ambulance service provided on 11/30/16 was not medically necessary for treatment of the patients medical condition. Based on the foregoing discussion, the service at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | ed6283ff20d35d47c82a5e7051139631 | ./data/processed/ca_cdi/summaries/18-6286.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 44-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan of parathyroid gland provided on 7/19/16. The Health Plan has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees hyperparathyroidism. The physician reviewer found the traditional approach to parathyroid surgery consists of bilateral neck exploration with the goal of identifying and visually inspecting all four parathyroid glands. However, in the past few decades imaging studies have made it possible to localize parathyroid adenomas preoperatively (Mohebati and Shaha). More recently, the fusion of SPECT with x-ray based CT has proved to be more accurate and sensitive for localization of adenomas and may also help provide additional anatomic information to the surgeon pre-operatively (Liddy, et al). Therefore, the SPECT scan of parathyroid gland provided on 7/19/16 has 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 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e49a3d5659b7c822cfe17cd0cd6a19ef | ./data/processed/ca_cdi/summaries/17-4922.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 44-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan of parathyroid gland provided on 7/19/16. The Health Plan has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees hyperparathyroidism. The physician reviewer found that in the medical literature, Eslamy and Ziessman noted that the clinical diagnosis of primary hyperparathyroidism is based largely on serum laboratory test results, as patients often are asymptomatic. Given that approximately 90% of cases are due to a single parathyroid adenoma, the procedure of choice is the selective surgical excision of the hyperfunctioning parathyroid gland after its preoperative identification and localization at radiologic imaging. The authors noted that SPECT, when combined with CT, is particularly helpful for preoperative localization: The three-dimensional functional information from SPECT is fused with the anatomic information obtained from CT. In addition, knowledge of the anatomy and embryologic development of the parathyroid glands and the pathophysiology of primary hyperparathyroidism aid in the identification and localization of hyperfunctioning glands. In this case, the patient presented with a diagnosis of primary hyperparathyroidism complicated by the presence of thyroid nodules. In this clinical setting, the minimally invasive parathyroidectomy procedure is the standard of care. Medical literature supports the use of SPECT/CT scan for the preoperative localization of the tumor. As such, the SPECT scan of parathyroid gland provided on 7/19/16 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 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e49a3d5659b7c822cfe17cd0cd6a19ef | ./data/processed/ca_cdi/summaries/17-4922.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 44-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan of parathyroid gland provided on 7/19/16. The Health Plan has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees hyperparathyroidism.The physician reviewer found the SPECT scan of parathyroid gland provided on 7/19/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is also ample literature to support its use in the surgical localization of parathyroid disease. The SPECT scan helps locate the anatomical abnormality and can enhance surgical precision, leading to better clinical outcomes for the patient, as well as help to shorten operative times. In conclusion, 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e49a3d5659b7c822cfe17cd0cd6a19ef | ./data/processed/ca_cdi/summaries/17-4922.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 41-year-old male enrollee has requested reimbursement for computed tomography (CT) of the head without contrast performed on 9/08/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the evaluation of the enrollees headaches. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. The medical evidence does not support CT scan of the head in this clinical setting. The American College of Radiology Appropriateness Criteria is divided into several categories. The one most closely reflects this patients presentation involves chronic headache, no new features, and normal neurologic examination. The American College of Radiology states, In adult and pediatric patients with migraine, but without recent change in attack pattern, history of seizures, or other focal neurologic symptoms or signs, the routine use of neuroimaging is usually unwarranted. The yield of CT or magnetic resonance imaging (MRI) in patients with headache but normal neurologic examination is generally quite low. Douglas and colleagues noted most patients presenting with uncomplicated, non-traumatic, primary headache do not require imaging. When history, physical, or neurologic examination elicits red flags or critical features of the headache, then further investigation with imaging may be warranted to exclude a secondary cause. All told, CT of the head without contrast performed on 9/08/16 was not medically indicated for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e8c6b050bf248f59fdfc588de2ac9711 | ./data/processed/ca_cdi/summaries/17-4817.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The parent of a 17-year-old female enrollee has requested reimbursement for residential treatment services provided from 8/26/15 through 12/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting. The Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted national standard for determining the appropriate level of care for children and adolescents. According to the CALOCUS criteria, this patients risk of harm is scored as a 3, significant risk of harm. The patient has a history of cutting, but she has not had any cutting since ninth grade. The parent had reported that the patient has had prior suicide attempts. The patient had been researching on the internet about suicide and wrote a suicide poem in January 2015. However, the RTC provider noted that she started having suicidal ideation in the 8th grade with the last reported suicidal ideation some time last year. It does not appear that she had presented suicidal ideations while at RTC. The patients functional status is scored a 3, moderate functional impairment. The patient graduated from a school that required accommodations due to learning impairments. The patient has some conflictual relationships with her family but is able to engage in interpersonal relationships. Recent gains in functioning have been achieved while participating in a structured setting. Her co-morbidity is assessed at a 3, significant co-morbidity. The patient has a co-morbidity of bipolar disorder, ADHD, learning disabilities, and emotional lability. Her environmental stress is scored a 3, moderately stressful environment. The patient has previously had frequent interpersonal conflicts with her parents. The patient has had prior physical altercations with her parents and have threatened to hurt her twin sister when she was younger. Her environmental support is a 2, supportive environment. The patient has supportive parents who are willing to participate in treatment if asked to do so. Her resiliency is scored a 2, positive response to treatment. The patient has documented improvement with the treatment she received at the wilderness program. Her acceptance and engagement is scored a 2, constructive. The patient is cooperative with treatment. The patient is able to develop a positive relationship with clinicians and care providers. At admission, the patient denied any suicidal or homicidal ideation. The patient reports that her mood had improved since discharging from the wilderness program. The provider felt that the patient was manic because the patient had rapid speech and grandiosity, but then stated that her mania was chronic and not cyclical suggesting it was tied with cognitive processing or personality development. It is noted that the patient was sleeping well and most notes document that the patient will speak rapidly. The provider reports that she her use of rapid speech as a way to accommodate deficits in her auditory memory. It appears there was uncertainty whether the patient was acutely manic at the time of admission or if this was the patients baseline way of communicating. This patients composite score using the CALOCUS criteria is 18.
Based on these criteria, the patient would have met criteria for a less restrictive program like an intensive outpatient program (IOP). The patient had shown significant improvement since being discharged from the wilderness program. The records do not support an admission to a RTC level of treatment nor did the records support the length of treatment at a highly restrictive environment from 8/26/15-12/31/16. While this patient required treatment for her bipolar disorder and ADHD, this could have been provided in a less restrictive environment. Accordingly, the residential treatment services provided from 8/26/15 through 12/31/16 were not medically necessary. Therefore, for the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 34d717ebd2684af66ace319c8193d39a | ./data/processed/ca_cdi/summaries/18-6158.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD), dysphagia and hiatal hernia. The physician reviewer found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other standard surgical anti-reflux procedures in the treatment of patients with GERD. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another evidence review found that further studies are required to determine its long-term outcomes and its relative efficacy as compared to other established treatments (Loh, et al). Adverse events, such as erosion through the esophagus, have been reported since U.S. Food and Drug Administration (FDA) approval (Bauer, et al). One peer-reviewed study reported that there are 11 cases of endoscopically-confirmed LINX erosion through the esophagus in the FDA Adverse Events database (Bielefeldt). Additionally, LINX has been associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al). The American College of Gastroenterology guidelines for the management of GERD also state that more evidence is needed before LINX can be recommended (Katz, et al). Based on current literature and clinical guidelines, the requested LINX procedure is not supported as medically necessary for the treatment of the 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e83f46126e5bc1d6b76d98c7f69cd29f | ./data/processed/ca_cdi/summaries/16-4759.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 57-year-old male enrollee has requested authorization and coverage for Euflexxa injections. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees osteoarthritis of the bilateral knees. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Axe and colleagues report that intra-articular (IA) viscosupplementation using hyaluronic acid (HA) demonstrates anti-inflammatory, anabolic, and analgesic effects. The authors state Use of IA HA has also shown to delay total knee arthroplasty. Moreover, the literature review by Cheng and colleagues state We conclude that strong evidence supports the use of intra-articular knee injection as a valuable intervention in the continuum of management of arthritis between conservative treatment and knee surgeries. In this case, the clinical documentation submitted for review indicates the patient has osteoarthritis of the bilateral knees. The patient has been treated with Euflexxa injections and reported relief from 2011 until 2014. As such, additional injections would be medically necessary in this clinical setting. Based on the medical records submitted and the peer-reviewed literature, the request for Euflexxa injections are medically necessary for the treatment of the patients medical condition. For the reasons provided, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | ce20539dadb1ff4a08ad5cc9d2e78ca5 | ./data/processed/ca_cdi/summaries/15-4128.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The parent of a 16-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 11/07/18 through 11/15/18. 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. With regards to risk of harm, the records support a score of 2. The documentation indicates that the patient was not actively suicidal but did report she was passively suicidal on one occasion. In terms of functional status, the records support a score of 2. The patient has 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 did not have a history of past medical issues or substance use. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was noted to have a good relationship with her family. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents are involved in treatment. With regards to resiliency and treatment history, the records support a score of 3. The patient had a good response to a short period in the residential treatment center with minimal continued signs or symptoms of anxiety and depression. She was participating in therapy while on the unit and was not displaying serious or disruptive symptoms. In terms of acceptance and engagement of the patient, the records support a score of 2. The records documented that the patient participated in therapy. With regards to acceptance and engagement of the parent, the records support a score of 2. The patients parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 16. This score correlates with intensive outpatient services. Therefore, mental health residential treatment provided from 11/07/18 through 11/15/18 was not medically necessary for the treatment of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 64ff45947908a64dd6affe6f7e9cb1cf | ./data/processed/ca_cdi/summaries/19-6597.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 60-year-old female enrollee has requested reimbursement for the gene test (gene expression profiling) CPT 84999 performed on 12/29/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is insufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. According to the results of analysis of patients melanoma performed with DecisionDx melanoma, the tumor was classified as Class 1B with a low risk of near-term (within five years) metastatic disease, such as 90% metastasis free rate. According to the standard analysis of such risk, the lesions of 1-2 mm depth have a risk of 80-96%. Although DecisionDx melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. Therefore, the gene test (gene expression profiling) CPT 84999 performed on 12/29/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 0202498ab274894ccc822d8f05568dc8 | ./data/processed/ca_cdi/summaries/17-6029.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 60-year-old female enrollee has requested reimbursement for the gene test (gene expression profiling) CPT 84999 performed on 12/29/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that in this clinical setting, the standard protocol for an intermediate thickness tumor does not include a work-up with molecular genetic testing. Although gene expression testing has shown some impressive results in predicting risk of metastasis, there is no set change in treatment protocol based on the findings. The standard of care in this clinical setting would be a wide local excision and a sentinel node biopsy and the decision to pursue medical treatment would be based on the results of these tests. There are no clinical studies at this time that show that the results of the molecular testing will make a difference in the treatment of the patient. As such, the gene test (gene expression profiling) CPT 84999 performed on 12/29/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 0202498ab274894ccc822d8f05568dc8 | ./data/processed/ca_cdi/summaries/17-6029.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 60-year-old female enrollee has requested reimbursement for the gene test (gene expression profiling) CPT 84999 performed on 12/29/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the gene test (gene expression profiling) CPT 84999 performed on 12/29/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx Melanoma Gene 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 the treatment of the patients melanoma. Thus its usage is not expected to impact the treatment or outcome of the patients melanoma. For the reasons provided, 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 0202498ab274894ccc822d8f05568dc8 | ./data/processed/ca_cdi/summaries/17-6029.jsonl | Insurer Denial 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.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 15e99eccf29ae080d04796c6db7048a8 | ./data/processed/ca_cdi/summaries/16-4737.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
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 the clinical utility of LHR is not well established and there are currently no national Allergy and Immunology or Dermatology guidelines recommending routine use of this test. LHR is a test that consists of basophil histamine release assay. This assay is used to detect anti-Fc-epsilon-RI-alpha antibodies. Some concerns with LHR is that there is evidence against a pathogenic role of autoantibodies to IgE or Fc-epsilon-RI and they are not specific to CU. Anti-Fc-epsilon-RI-alpha antibodies have been identified in healthy normal people and those with other autoimmune diseases. The level of these antibodies do not appear to change with the clinical disease activity. The presence of these antibodies do not appear to predict refractory disease. In this patients case, her symptoms are consistent with chronic idiopathic urticaria. Her evaluation to include LHR have all been negative. As such, (CPT code 86343) leukocyte histamine release test (LHR) that was rendered on 10/20/15 was not likely to have been more effective than current standard therapy for evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 15e99eccf29ae080d04796c6db7048a8 | ./data/processed/ca_cdi/summaries/16-4737.jsonl | Insurer Denial Upheld | Experimental |