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Summary Reviewer 1
The patient is a 46-year-old female with a history of right hip pain. The patients hip pain has not responded to conservative treatment in addition to revision arthroscopic labral debridement, iliopsoas bursectomy, synovectomy, lysis of adhesions, and capsular release. The patient has requested authorization and coverage for AmnioFix injection. The Health Insurer has denied this request indicating that the requested service is considered investigational. While intraarticular stem cell injections for osteoarthritis have been evaluated in clinical trials, it is not currently a standard treatment for hip osteoarthritis. In addition, there is a lack of data regarding the clinical safety including the risk of complications after surgery, compatibility of donor stem cells, and long-term effectiveness. There is an insufficient amount of clinical data demonstrating superiority of amniotic fluid injections when compared with pharmacological treatments for osteoarthritis. Given the adverse biomechanical nature of a dysplastic hip, injections of amniotic stem cells, or stem cells of any derivative, are not likely to provide any lasting relief. Thus, the requested AmnioFix injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 1016d4564a8a6e01d4604c1e220c00fe | ./data/processed/ca_cdi/summaries/17-5001.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
The patient is a 46-year-old female with chronic pain at the hip joint. The patients pain has reportedly been present since 2011, treated with physical therapy, steroid injections and arthroscopic labral surgeries. A diagnosis of right labral tear was made in 2011. Arthroscopic surgery was recommended in an attempt to repair the labrum. There were multiple complications following this surgery with a total of four surgical procedures in 13 months. Pain in the hip joint continued. In 2015, a fifth surgical procedure was performed with initial improvement in symptoms followed by recurrence in symptoms. X-rays on 12/8/16 demonstrated moderate medial femoral acetabular osteoarthritis with joint space narrowing as well as moderate osteoarthritis with joint space narrowing. The patient has requested authorization and coverage for AmnioFix injection. The Health Insurer has denied this request indicating that the requested service is considered investigational. AmnioFix is described as a composite amniotic membrane substance containing growth factors unique to placental tissue. AmnioFix has been utilized in the treatment of ocular burns, conjunctival injuries, and in sheet form for wound care. AmnioFix injections have been recommended in a number of orthopedic conditions including plantar fasciitis and Achilles tendonitis. In this particular patient, anatomical changes are likely to have already occurred within the labrum and the patient has joint space narrowing such that molecular level interventions are not likely to have a positive effect. Given these findings, the requested AmnioFix injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 1016d4564a8a6e01d4604c1e220c00fe | ./data/processed/ca_cdi/summaries/17-5001.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
The patient is a 46-year-old female with chronic right hip pain. She had undergone labral repairs, debridement, and a periacetabular osteotomy and was still unable to ambulate more than one mile. She complains of pain in the anterior groin and lateral hip described as sharp, radiating, and associated with stiffness. She also has mechanical symptoms in the hip such as catching/locking, giving way, and stiffness. On examination the gait was antalgic. Right hip flexion was 120 degrees, internal rotation was 20 degrees, external rotation was 40 degrees, and extension was 10 degrees. There was pain with range of motion. X-rays revealed medial osteoarthritis with joint space narrowing of the right hip. In 2011, it was discovered that she had severe dysplasia which caused a tear in the right labrum. She underwent a periacetabular osteotomy and repair of the labrum. Due to complications, she underwent four hip surgeries in the subsequent 13 months followed by a fifth surgery in 2015. The labrum tore again a few months later. Treatment options discussed included hip replacement and an AmnioFix injection. The patient has requested authorization and coverage for AmnioFix injection. The Health Insurer has denied this request indicating that the requested service is considered investigational. Degenerative joint and tendon injuries remain difficult to treat in patients with few effective conservative treatment options. Regenerative approaches aim to promote the inherent healing capacity of injured tissues. Micronized dehydrated human amnion/chorion membrane (dHACM) injection is an emerging regenerative option with promising preclinical and clinical results. Gellhorn and Han reported that dHACM was clinically effective in reducing pain and improving function in the majority of adults enrolled in the study. Zelen and colleagues reported there are limited data available regarding most amniotic membrane-based products. However, there is substantial preclinical and clinical evidence supporting the rationale and effectiveness of dHACM allograft as a treatment modality. As such, a trial of micronized dehydrated human amnion/chorion membrane injection (AmnioFix) is a good option for this patient which is likely to be more effective than any other standard treatment for her medical condition. Based upon the information set forth above, the requested service 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:: | 1016d4564a8a6e01d4604c1e220c00fe | ./data/processed/ca_cdi/summaries/17-5001.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 54-year-old male enrollee has requested authorization and coverage for Sovaldi and Olysio. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. Per the guidelines, patients with cirrhosis are high priority for treatment. After failure of NS5A inhibitors such as Harvoni, AASLD/IDSA guidelines state that patients who are high priority for treatment (such as this patient) should undergo testing for resistance-associated variants and retreatment when possible. When resistance to NS5A inhibitors is present and NS3 resistance is absent, as in this case, the recommended therapy is Sovaldi and Olysio with ribavirin for 24 weeks based on the resistance testing profile (Lawitz, et al; Buti, et al). For these reasons, the requested treatment with Sovaldi and Olysio is supported as medically necessary for the treatment of this patients hepatitis C infection. Therefore, based on the reasons stated above, the requested medications 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:: | f1f686d639f260cb3b77abd52b615e93 | ./data/processed/ca_cdi/summaries/16-4787.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 34-year-old male has requested reimbursement for polymerase chain reaction (PCR) testing performed on 8/03/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the current medical evidence does not support the services at issue in this clinical setting. The patient likely had a viral exanthem. He is treated with an antibiotic for presumed strep infection. The records do not support a clinical reason for ordering PCR testing. The treatment would not change based on this testing. Therefore, PCR testing performed on 8/03/17 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:: | 98107fd9f4c9d6291c8de634965efcbe | ./data/processed/ca_cdi/summaries/18-6383.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 34-year-old male has requested reimbursement for polymerase chain reaction (PCR) testing performed on 8/03/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the EBV infection can be suspected with an appropriate clinical presentation of sore throat, fever, and malaise with enlarged lymph nodes on examination. The recommended laboratory testing for a case of EBV infection causing mononucleosis is a complete blood count and liver enzymes and heterophile antibodies. In this case, the patient presented with a recent pharyngitis and rash after treatment with an antibiotic. At the time of presentation, the patient noted improved symptoms with treatment of the antibiotic, and there was no fever or enlarged lymph nodes on examination. The concern was for EBV infection causing mononucleosis. The testing with a complete blood count was unremarkable, and the appropriate test for EBV infection would have been heterophile antibody testing. The requested PCR would not be more beneficial in this case than the recommended testing, heterophile antibody testing. In sum, PCR testing performed on 8/03/17 was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 98107fd9f4c9d6291c8de634965efcbe | ./data/processed/ca_cdi/summaries/18-6383.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 34-year-old male has requested reimbursement for polymerase chain reaction (PCR) testing performed on 8/03/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the patient did not have clinical evidence of infectious mononucleosis. The evaluation on 8/03/17 suggests a viral pharyngitis. He had already been given an extended spectrum penicillin antibiotic. The rash was not suggestive of mononucleosis. This disease may cause a macular rash, but it does not produce a pustular eruption. Importantly, the patient did not have a lymphocytosis. Additionally, PCR testing on blood is not a test used to make a diagnosis of monoucleosis. The tests sole use is in highly immunocompromised individuals who may have a viremic illness. Thus, PCR testing performed on 8/03/17 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:: | 98107fd9f4c9d6291c8de634965efcbe | ./data/processed/ca_cdi/summaries/18-6383.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 30-year-old male enrollee has requested reimbursement for L0637 (lumbar support brace) provided on 1/7/15. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees low back pain. The physician reviewer found that based on the clinical records submitted for review, the L0637 (lumbar support brace) provided on 1/7/15 was not medically necessary for treatment of the patients medical condition. The office visit dated 1/7/15 does not provide sufficient rationale supporting the clinical indication for the lumbar support brace provided. On 1/7/16, the office visit indicates that the patient reports to improving 10% since the onset. Given that the patient had improved and in the absence of clinical rationale supporting the device, the L0637 (lumbar support brace) provided on 1/7/15 was not medically necessary for treatment of the patients medical condition. Therefore, 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:: | 30cb923c8b025b2290db790725e00cab | ./data/processed/ca_cdi/summaries/17-6079.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 69-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis without contrast material, followed by contrast material and further sequences (CPT 72197). The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees rising prostate specific antigen (PSA) levels. The physician reviewer found that the American Urological Association (AUA) guidelines do not advocate the use of multiparametric MRI as a routine screening tool for prostate cancer. However, the current medical literature has demonstrated that in certain patients, multiparametric MRI offers an advantage not afforded by transrectal ultrasound (TRUS) guided biopsy. Such is the case for this patient. The patients steady rise of PSA with tripling of the value over three years is a concern for prostate cancer. The literature reports that there can be significant risk with TRUS guided biopsy with significant false negatives since the cores are randomly obtained. The use of multiparametric MRI allows the stratification of risk for aggressive tumor and compares more favorably to random biopsies. This patient is at risk for prostate cancer due to steadily rising PSA. Thus, for this particular patient, the requested multiparametric MRI is medically necessary for further evaluation of his medical condition. Based on the foregoing discussion, the requested services are 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:: | aad2d31c60517b1786cd57613527f85b | ./data/processed/ca_cdi/summaries/18-6398.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 31-year-old female enrollee has requested reimbursement for inpatient mental health services provided from 11/7/17 to 12/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder and depression. The physician reviewer found that applying the level of care utilization system (LOCUS) criteria, the inpatient mental health services provided from 11/7/17 to 12/6/17 were not medically necessary for treatment of this patients behavioral health issues. The patient presented with significant risk of harm (score 3) with a history of a suicide attempt at age 15 by attempting to overdose on Advil. The patient also has a history of self-cutting from the ages of 14-19 years old. On 11/7/17 and several days prior, the patient had intermittent passive suicidal thoughts. The patient demonstrated moderate functional impairment (score 3) and due to her symptoms, the patient was unable to fulfill her responsibilities in her work. The patient showed significant co-morbidity (score 3) with history of bipolar II, cluster B traits, and bingeing, purging, and restricting behaviors. The patient did not have substance abuse problems. The patients recovery environment is mildly stressful (score 2) as she demonstrated distress while she was traveling in Paris due to isolation. The patients recovery environment was supportive (score 2) and she demonstrated moderate response to prior treatment (score 3). The patient demonstrated positive engagement and recovery (score 2) as she was described as attentive and engaged during treatment. The patient had a positive attitude toward recovery and treatment. These findings give the patient a composite score of 18, which is consistent with intensive outpatient program (IOP) level of care. The patient continued to require treatment for her of bipolar II, cluster B traits, and bingeing, purging, and restricting behaviors, but this could have been safely and effectively provided in a less restrictive environment. Therefore, the services at issue were not medically necessary. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | [
"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:: | 5a6b66017990d3ed4daea7dd6edcf11d | ./data/processed/ca_cdi/summaries/18-6284.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 45-year-old female enrollee has requested authorization and coverage for arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees back pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this clinical setting. This patient presents with persistent severe right greater than left SI joint pain. Functional difficulty was documented in sitting tolerance, activities of daily living, and work ability. She was status post circumferential L3-S1 instrumented fusion in May 2014 with initial positive surgical benefit allowing return to work. She reported progressively worsening bilateral buttocks pain. There was evidence of long-term conservative treatment including medications, activity modification, SI joint injections, sacroiliac radiofrequency ablation, and physical therapy without sustained improvement. Clinical examination findings have documented SI joint tenderness with four positive sacroiliac provocative testing. There was radiographic evidence of bilateral sacroiliac arthropathy, right greater than left, consistent with adjacent segment degeneration. Multiple SI joint injections have been documented with 100% relief on the day of injection and diminishing response over time. In this patients case, the current evidence based medical guideline and peer-reviewed surgical indications for SI joint fusion have been met. In sum, arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance is medically necessary for treatment of this patient. Therefore, for the reasons stated above, 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:: | 109b82ae81ecb5b3ada2ad4b2129c8e7 | ./data/processed/ca_cdi/summaries/17-4870.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 62-year-old male enrollee has requested reimbursement for testing for liver disease provided on 6/11/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that FibroTest and FibroSure are identical proprietary tests marketed under different names in Europe and America, respectively. ActiTest is a modification of FibroTest. The tests have primarily been studied in patients with hepatitis B and C. FibroTest involves assessment of alpha-2-macroglobulin, alpha-2-globulin, gamma globulin, apolipoprotein A1, and total bilirubin. It also takes into account the patients age and sex. Results from the individual assays are combined and are used to classify patients having mild fibrosis (F0 to F1), significant fibrosis (F2 to F4), or an indeterminate stage of fibrosis. The sensitivity for detection of significant fibrosis is approximately 60 to 75 percent, and the specificity is approximately 80 to 90 percent. In clinical practice, the services at issue are used routinely in patients with hepatitis B. Therefore, testing for liver disease (FibroTest-ActiTest/HCV-FibroSure) provided on 6/11/19 was likely to have been more beneficial than other methods of evaluating 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:: | d4c5a3a1e26c5e8fa3f871ff031284d4 | ./data/processed/ca_cdi/summaries/19-6866.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 62-year-old male enrollee has requested reimbursement for testing for liver disease provided on 6/11/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that in chronic hepatitis B patients, such as this patient, identification of cirrhosis defines treatment endpoints and options. Non-invasive studies, such as FibroTest, are typically applicable to the hepatitis C population, and those with other chronic liver conditions. Relative to FibroTest itself, Jieanu and colleagues opined Fibrotest is a patented formula which involves several parameters: total bilirubin, haptoglobin, gamma glutamyl transpeptidase, a2-microglobulin apolipoprotein-A, age and gender, with the results correlated with the METAVIR score. This evaluation is the most used indirect marker showing excellent results in a meta-analysis in chronic hepatitis C (CHC). Supporting this contention, Parikh and colleagues concluded that FibroTest is useful in ruling out chronic hepatitis B-related cirrhosis. Thus, while liver biopsy remains the gold standard for assessment of hepatic fibrosis, the assay under review in this case provides ready assessment of progression to cirrhosis without the inherent risks of invasive testing. In sum, testing for liver disease (FibroTest-ActiTest/HCV-FibroSure) provided on 6/11/19 was likely to have been more beneficial than other methods of evaluating 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:: | d4c5a3a1e26c5e8fa3f871ff031284d4 | ./data/processed/ca_cdi/summaries/19-6866.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 62-year-old male enrollee has requested reimbursement for testing for liver disease provided on 6/11/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that FibroTest has demonstrated that it reliably determines the presence of advanced fibrosis and cirrhosis in a variety of liver diseases which can cause continuously advancing liver injury, including hepatitis B. It is important to identify cirrhosis early, as it requires specific and routine monitoring, such as ultrasound every six months, to prevent complications. Liver biopsy, by contrast, is invasive, with risks including bleeding and bile duct injury. It is subject to interoperator variability during interpretation and is also subject to sampling error. Thus, testing for liver disease (FibroTest-ActiTest/HCV-FibroSure) provided on 6/11/19 was likely to have been more beneficial than other methods of evaluating 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:: | d4c5a3a1e26c5e8fa3f871ff031284d4 | ./data/processed/ca_cdi/summaries/19-6866.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The parent of a 14-year-old female enrollee has requested reimbursement for mental health residential treatment center services provided from 11/16/16 through 12/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the mental health residential treatment center services provided from 11/16/16 through 12/6/16 were not medically necessary for treatment of the patients medical condition. According to Mehler, Anorexia nervosa is a psychiatric disorder characterized by abnormal eating behaviors that results in weight loss and has serious potential medical consequences. Most of these complications are readily treatable if diagnosed and attended to early in the course of the illness. Outpatient treatment with modalities such as cognitive behavioral therapy (CBT) can be effective for significantly reducing relapse risk and increasing the likelihood of good outcomes compared with nutritional counseling in the treatment of anorexia nervosa (Bulik, et al). CBT is commonly used on an outpatient basis. Moreover, in most cases outpatient treatment is recommended with hospital admission indicated for those at risk of medical and/or psychological compromise (Hay, et al). In this case, the patient was medically and psychiatrically stable. As of 11/16/16 the patient had stabilized and was eating appropriately. She was at 86% of her ideal body weight. Her medical status was intact and described as psychiatrically stable. She had some laboratory abnormalities that could have been addressed on an outpatient basis and she did not have unstable coexisting health problems. She was not exhibiting severe mood, anxiety or psychotic symptoms and was not engaging in self-harm type behaviors. Based on the clinical documentation submitted for review, the patient could have been treated safely and effectively at a lower level of care as of 11/16/16. 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:: | 313d3260e829da9e1f63b797766a1318 | ./data/processed/ca_cdi/summaries/17-6017.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 60-year-old female enrollee has requested reimbursement for genomic analysis performed on 6/15/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ovarian cancer. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. In order to demonstrate the clinical utility of panel testing for somatic genomic alterations, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with the standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make conclusions on clinical utility. In addition, there is potential for harm if ineffective therapy is given based on test results. Therefore, genomic analysis performed on 6/15/17 was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | a7a1c12e446211008c0907aff03254b2 | ./data/processed/ca_cdi/summaries/18-6505.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 60-year-old female enrollee has requested reimbursement for genomic analysis performed on 6/15/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ovarian cancer. The physician reviewer found that the current medical evidence supports a portion of the services at issue. FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. It has not been determined if molecular markers are useful in treatment determination (predictive markers). There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. Patients who are microsatellite instable (MSI) can be treated with Keytruda. In this patients case, there is support for MLH1, MSH2, MSH6 and PMS2 testing. However, the superior efficacy of the remaining of the services at issue has not been established. Based upon the information set forth above, a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be partially overturned.
| [
"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:: | a7a1c12e446211008c0907aff03254b2 | ./data/processed/ca_cdi/summaries/18-6505.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 60-year-old female enrollee has requested reimbursement for genomic analysis performed on 6/15/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ovarian cancer. The physician reviewer found that there are many agents with activity against recurrent ovarian cancer. Thus, treatment off-label is very common. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues published a study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progression-free on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. The patient is out of standard options and will be offered something off-label. The mutational testing as ordered was medically appropriate. Thus, genomic analysis performed on 6/15/17 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the 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:: | a7a1c12e446211008c0907aff03254b2 | ./data/processed/ca_cdi/summaries/18-6505.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency. The physician reviewer found that there is evidence 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, and the long-term efficacy of percutaneous tibial nerve stimulation is largely unknown. American Urological Association guidelines recommend behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, and fluid management) as first-line therapy to patients with overactive bladder. Behavioral therapies may be combined with pharmacologic management. Clinicians should offer oral antimuscarinics or oral beta 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, different anti-muscarinic medication or a beta 3 adrenoceptor agonist may be tried. Botox injection is a standard third-line therapy and is graded better. Percutaneous tibial nerve stimulation has not been proven to be superior to other alternatives. Studies have compared percutaneous tibial nerve stimulation to anticholinergics and have demonstrated comparable efficacy. As such, the superior efficacy of nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18 has not been established. 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:: | e295ef40728d9c88b55bc983111b9e18 | ./data/processed/ca_cdi/summaries/18-6434.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency. The physician reviewer found that the submitted records fail to demonstrate the superior efficacy of the services at issue. The current literature has not established that percutaneous tibial nerve stimulation is of greater benefit than standard methods of treating this patients condition. This patient may benefit from medications, hydrodistention, intravesical therapy and pelvic floor biofeedback. Per the records, first-line and second-line treatments have not been systematically trialed and exhausted. In sum, nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18 was not likely to have been more efficacious 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:: | e295ef40728d9c88b55bc983111b9e18 | ./data/processed/ca_cdi/summaries/18-6434.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency. The physician reviewer found that intractable lower urinary tract symptoms and painful bladder/urethral syndrome related to interstitial cystitis can be clinically difficult to treat. Treatment options often are limited and have variable results. Patients often receive multimodal treatment, including proceeding to secondary and tertiary treatment options. Percutaneous tibial nerve stimulation is considered as a tertiary treatment option for intractable lower urinary tract symptoms and painful bladder syndrome with urgency frequency syndrome. There is some support for the requested services in this clinical setting. Therefore, nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18 was likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned. | [
"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:: | e295ef40728d9c88b55bc983111b9e18 | ./data/processed/ca_cdi/summaries/18-6434.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 65-year-old female enrollee has requested authorization and coverage for spinal surgery (CPT codes 22212, 63048, 22610, 20931, 63046, 22840, 22842, 22853, 22845, 22556, 22216, 63077, and 22614) and five (5) inpatient days. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees back pain. The physician reviewer found that in the medical literature, Resnick and Groff noted that lumbar fusion is performed for the treatment of painful instability of the spine, usually manifest as chronic low back pain. The documentation available for review does not include evidence of any instability in the thoracic spine. Further, there is no severe stenosis or deformity. The medical records indicate that this patient underwent previous lumbar and cervical fusion surgeries and presents with 50 degrees of kyphosis in the mid-thoracic spine. However, 50 degrees of kyphosis is considered mild in the thoracic spine and does not support the need for fusion. (Chou, et al; Resnick). All told, the requested spinal surgery (CPT codes 22212, 63048, 22610, 20931, 63046, 22840, 22842, 22853, 22845, 22556, 22216, 63077, and 22614) and five (5) inpatient days is not supported as medically necessary for treatment of this patients back pain. Based on the foregoing discussion, he requested services 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:: | 6c7428b718a9f863c6297e5a5c48f0d9 | ./data/processed/ca_cdi/summaries/18-6453.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
An 18-year-old transgender female enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 11/19/17 through 3/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. In terms of risk of harm, the records support a score of 1. The medical records indicated that the patient was not actively suicidal. With regards to functional status, the records support a score of 2. The patient had some issues with level of function due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment. In terms of comorbidity, the records support a score of 1. The patient did not have a history of active serious medical issues or substance use. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have strained relationship with family and indicated some mild stress at home. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient
had some outpatient mental health therapy prior to residential admission but continued to have symptoms of anxiety. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy. In terms of acceptance and engagement of the parents, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 15. This score correlates with outpatient services. Therefore, residential mental health treatment from 11/19/17 through 3/08/18 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:: | aaee7c71ad0cb90a1c1446f1d237dd0e | ./data/processed/ca_cdi/summaries/19-6651.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 20-year-old male enrollee has requested reimbursement for substance use disorder partial hospitalization program (PHP) services provided from 10/3/17 through 10/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the substance use PHP services provided from 10/3/17 through 10/6/17 were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient was not a danger to himself or others, and he was not aggressive or violent. His post-acute withdrawal symptoms were not reported. There were no significant emotional, behavioral, or cognitive symptoms that would warrant continued PHP level of care. There was no high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would have prevented stepping him down to a lower level of care. He was medically and psychiatrically stable. He remained in partial denial about his problem with alcohol. There was no documentation of significant progress, change in medications, and change in treatment plan, or mental status examinations. He had support systems in place. The source of his anxiety and depression were not clear and did not appear to be addressed in the PHP treatments. Thus, the patients continued recovery efforts, and development of coping skills could have been accomplished in IOP level of care or outpatient. He was working on issues in DBT/CBT groups, which could have been provided on an outpatient basis. As such, the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | [
"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:: | be332dbc2c809a79bc6c2507b7cb024a | ./data/processed/ca_cdi/summaries/17-6141.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma. The physician reviewer found that the DecisionDX is a study of 15 to 31 genes in a patients melanoma cells. It has been used to classify the individuals melanoma as having either a high or low risk of metastasis. It is controversial in cutaneous melanoma as to whether it has additional value when added to the usual pathologic prognostic factors. However, it is particularly useful in the analysis of uveal melanoma and has been validated in several studies. Specifically, a Class 1 category carries with it a less than 20% chance of metastasis, whereas Class 2 has a greater than 70% chance of metastasis. This testing has become a standard in many ocular cancer centers. Its clinical value lies in determining the need for intense surveillance, and possibly to assist in the decision as to adjuvant therapy. Therefore, DecisionDX-UM assay performed on 5/09/16 was likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | fd40de0df2be50b4f833e339e3835cc8 | ./data/processed/ca_cdi/summaries/17-4929.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma. The physician reviewer found there is sufficient support for DecisionDX-UM assay in this clinical setting. The testing performed is considered a standard of care in patients with ocular (uveal) melanoma. This is a rare type of melanoma treated by only a handful of experts. DecisionDX-UM assay provides prognostic and predictive information to guide adjuvant therapy for patients with uveal melanoma using genomic testing of the tumor. Thus, DecisionDX-UM assay performed on 5/09/16 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | fd40de0df2be50b4f833e339e3835cc8 | ./data/processed/ca_cdi/summaries/17-4929.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma. The physician reviewer found that this patient has a rare disease, ocular melanoma, which has a poor prognosis once it metastasizes. However, knowledge of the propensity for metastasis directly affects surveillance of patients by computed tomography (CT) scan. Along these lines, two clinical studies have been done using the gene expression classifier Decision DX-UM that defines two classes of ocular melanoma. Class 1 is associated with a low risk of metastasis and Class 2 has a 50% risk at two years and 72% risk at five years. There is no other standard prognostic indicator that could serve as an alternative. Thus, the current medical evidence favors the use of this test in the postoperative surveillance of patients with ocular melanoma. In sum, DecisionDX-UM assay performed on 5/09/16 was likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | fd40de0df2be50b4f833e339e3835cc8 | ./data/processed/ca_cdi/summaries/17-4929.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The guardian of a 17-year-old male enrollee has requested reimbursement for residential treatment provided from 6/05/14 through 10/11/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue. This patient had a history of substance abuse, truancy, running away, defiance, and risky and self-destructive behavior. This patient engaged in the therapeutic environment, albeit he was initially resistant to change. He reportedly showed some progress. Given this patients level of his behavioral problems, his familys lack of ability to control him, and his defiance of authority, he was not likely to have been receptive to or cooperative with a lower level of care. Based upon the medical records, this patient could not have effectively been treated at a lower level of care. He needed long-term treatment for both substance abuse and behavioral health conditions in a restricted environment. All told, residential treatment provided from 6/05/14 through 10/11/14 was medically indicated for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| [
"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:: | 8e7df64487c92ba46ed0bd341b9d5742 | ./data/processed/ca_cdi/summaries/15-4176.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 64-year-old female who was transported by air ambulance from Brazil to Cedar Sinai Hospital (CSH) in Los Angeles, California on 1/18/20. The patient has requested reimbursement for air ambulance transport services provided on 1/18/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that in order for air medical transport to be medically necessary, medical necessity criteria must be met. The patientas condition must be such any form of transportation other than ambulance would be medically contraindicated. Additionally, and the patientas condition is such that time needed to transport by ground poses a threat to the patientas survival, and there is a medical condition that is life-threatening. Such conditions include, but are not limited to, intracranial bleeding, cardiogenic shock, major burns, conditions requiring hyperbaric oxygen, multiple severe injuries, transplants, limb-threatening trauma, or acute myocardial infarction requiring intervention, such as percutaneous transluminal coronary angioplasty. When transporting from one facility to another, the above criteria must be met and the first hospital must not have the required services and facilities to treat the patient. Further, when transferring from one hospital to another, the patient must be transported to the nearest hospital with appropriate facilities for treatment. This patient asserts that the facility she was admitted to in Brazil was not capable of providing appropriate care. Review of the available records indicates otherwise. The patient also states she required admission to a rehabilitation unit and there are no such facilities in Brazil. If such were the case, then transport would have needed to be to the closest facility capable of providing that care. Records do document that the patientas family had requested she be transferred to CSH in Los Angeles, California, to be closer to home and family. Therefore, air ambulance transport services provided on 1/18/20 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:: | ac8f4ac1c03b1cf8aaee190a82a9b7b2 | ./data/processed/ca_cdi/summaries/20-7076.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 64-year-old male enrollee has requested authorization and coverage for functional electrical stimulation cycle ergometer. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees tetraplegia. The physician reviewer found that the patient has a spinal cord injury that results in reduced mobility and reduced ability to engage in exercise. Functional electrical stimulation cycling has been developed as a means to stimulate muscle activity in paralyzed limbs to reproduce physiological effects of exercise. The literature has explored the effects of functional electrical stimulation cycling to determine if this artificial form of exercise has clinical benefit. The net weight of evidence has been positive, showing that functional electrical stimulation cycling promotes improved health status in people with spinal cord injury. There is sufficient support for the requested device in this clinical setting. Thus, the requested functional electrical stimulation cycle ergometer is medically necessary in this patients case. Therefore, 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:: | d091c9df0b7e2b7f7c94b9a1b38a6926 | ./data/processed/ca_cdi/summaries/18-6460.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 51-year-old female enrollee has requested authorization and coverage for Vemlidy. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B virus. The physician reviewer found that according to the American Association or the Study of Liver Disease (AASLD) guidelines for treatment of hepatitis B, tenofovir is the first-line recommended therapy for the treatment of hepatitis B (Terrault, et al). Per AASLD guidelines, the goal of therapy is long term viral suppression, unless there is clear seroconversion, when applicable, and long-term undetectable viral DNA. In addition, the Vemlidy formulation of tenofovir is effective for hepatitis B and associated with fewer adverse effects, including osteopenia compared to Viread (Grant, et al). For these reasons, Vemlidy is supported as medically necessary for the treatment of the patients hepatitis B infection.
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:: | c4de43a7df79809e730faf817d91cef5 | ./data/processed/ca_cdi/summaries/17-4949.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 35-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram provided on 10/31/16. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found that the 3D mammogram provided on 10/31/16 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two dimensional (2D) and 3D mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the documentation submitted for review and medical literature cited above, 3D mammogram was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 62b8a3e19cb71cfa62df83145933950b | ./data/processed/ca_cdi/summaries/17-4975.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 35-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram provided on 10/31/16. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found that 3D mammograms, also known as tomosynthesis was approved for clinical use by the U.S. Food and Drug Administration in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of mammography the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantage it brings providers interpreting mammograms especially in women with dense tissue such as the patient under review. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in overall diagnostic accuracy compared to two-dimensional mammography. In this case, the palpable abnormality was better assessed using tomosynthesis in this patient with a strong family history and dense tissue. All told, the 3D mammogram provided on 10/31/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 62b8a3e19cb71cfa62df83145933950b | ./data/processed/ca_cdi/summaries/17-4975.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 35-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram provided on 10/31/16. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found that in this case, the 3D mammogram was clinically indicated for this patient. The patients breasts are described as extremely dense. It is specifically those patients who have dense breasts that can benefit most from 3D mammogram. The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor. In addition, the patient presented with a palpable lump. Once a lump is palpated, it is imperative to determine whether a mass is present. For the reasons provided, the 3D mammogram provided on 10/31/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 62b8a3e19cb71cfa62df83145933950b | ./data/processed/ca_cdi/summaries/17-4975.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The parent of a 16-year-old male enrollee has requested reimbursement for mental health outpatient services provided from 11/25/15 through 5/12/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found that reviewing therapy progress notes including those from 11/25/15, 12/17/15 and 3/17/16 it was consistently noted that the patient had restlessness, depression, but there was no documentation of any evidence that would warrant extended outpatient sessions. There was no indication that the patient was in crisis or decompensating, or that he required specialized services that would require extended sessions. Overall, the records provided for review suggest this patient could have been reasonably and adequately treated with less intrusive, less invasive level of care, such as regular outpatient therapy sessions. Accordingly, the mental health outpatient services provided from 11/25/15 through 5/12/16 were not medically necessary for treatment of this patients medical condition. Based on the records provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| [
"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:: | 4d9bfb7f527107abc07cc303d9f13ae0 | ./data/processed/ca_cdi/summaries/17-4796.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
The patient is a 44-year-old female who has a personal history of several malignancies including bilateral invasive lobular breast cancer at age 42, non-Hodgkins lymphoma in 1997, thyroid cancer in 1998, and a mucoepidermoid carcinoma of the trachea in 2009. Her family history is significant for a sister with thyroid cancer at age 34. The records noted a sister was diagnosed with non-Hodgkins lymphoma at 42. Her paternal grandmother was diagnosed with uterine cancer in her 60s, her mother was diagnosed with thyroid cancer at 66, two maternal cousins were diagnosed with thyroid cancer, and a maternal uncle was diagnosed with leukemia at age 18. The patient has requested reimbursement for gene testing performed on 11/28/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. This patient has an extensive personal history of cancer, including breast cancer before the age of 50 that was bilateral. Her family history is also suggestive of a familial genetic predisposition to thyroid cancer on the maternal side. More than one gene could explain the patients genetic risk of cancer. If a gene is identified, this could help guide prevention and treatment strategies. This patient meets criteria for BRCA1 and BRCA2 testing. The largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5 to 10 percent have a BRCA1 or BRCA2 mutation, and about 4 to 7 percent have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may also be associated with increased risks for these cancers. She also has a significant family history, and testing positive for a mutation would guide additional therapy, such as mastectomy or oophorectomy as well as how to manage her screening for another breast cancer or other cancer. The medical evidence supports the services at issue in this clinical setting. All told, gene testing performed on 11/28/16 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | a307c442fb33bec91fd90d884c77b56a | ./data/processed/ca_cdi/summaries/17-6039.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
The patient is a 44-year-old female who has had bilateral breast cancer. In addition, she has also had non-Hodgkins lymphoma and mucoepidermoid cancer. She has a strong family history of cancer, with a sister with lymphoma, sister with thyroid cancer and a paternal grandmother with uterine cancer. There are other members of the family with thyroid cancer. In November 2016, her blood was submitted for the MyRisk genetic susceptibility panel. The patient has requested reimbursement for gene testing performed on 11/28/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. BRCA testing guidelines recommend BRCA testing for this patient as she was diagnosed with breast cancer at the age of 42. However, at issue is the MyRisk panel, which is a 25 gene panel that includes BRCA within it, but also a variety of other suspected risk genes. Although many of these gene mutations are of real interest and are being actively studied, for the most part they have as yet not been found to be significant or predictive enough to be the basis for clinical decisions by the carriers or their family members. Such panel testing is not included in the guidelines from major organizations. Thus, gene testing performed on 11/28/16 was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | a307c442fb33bec91fd90d884c77b56a | ./data/processed/ca_cdi/summaries/17-6039.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
The patient is a 44-year-old female with a history multiple malignancies, including breast cancer. Per the records, she had an abnormal uterine ultrasound. She has a significant family history, including a sister with non-Hodgkins lymphoma, a sister with thyroid cancer, two cousins with thyroid cancer, and a mother with thyroid cancer. The history was suggestive of a familial predisposition of cancer which prompted testing using the MyRisk panel. The patient has requested reimbursement for gene testing performed on 11/28/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. This patients family history is suggestive of a breast/ovarian cancer syndrome. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed, in no particular order, by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral. In this patients case, the MyRisk panel was appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Thus, genetic testing performed on 11/28/16 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:: | a307c442fb33bec91fd90d884c77b56a | ./data/processed/ca_cdi/summaries/17-6039.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
The parent of a one-year-old male enrollee has requested authorization and coverage for Olumiant
1 mg tablet. The Health Insurer has denied this request and reported that the requested medication
is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. Aicardi-
GoutiA res Syndrome (AGS) is recognized as a Type 1 interferonopathy, which leads to
autoimmune-mediated inflammation. Uncontrolled autoimmune inflammation results in a wide
range of disease manifestations with the central nervous system (CNS), in particular, being
affected. This is an important point to make, because any conventional FDA-approved medicine
that treats CNS disease, including all available antiepileptic medications, does not address the
underlying disease processes in AGS. In this patientas case, Olumiant therapy offers the chance
for a marked reduction in AGS-associated morbidity. Therefore, Olumiant 1 mg tablet is likely to
be more beneficial than other available standard therapy.
| [
"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:: | a8114bb1aeb33e4be9a8f42e66f9cb8b | ./data/processed/ca_cdi/summaries/20-7214.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
The parent of a one-year-old male enrollee has requested authorization and coverage for Olumiant
1 mg tablet. The Health Insurer has denied this request and reported that the requested medication
is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that AGS is a rare monogenic interferonopathy characterized by variable neurologic dysfunction,
ranging from mild spastic paraparesis to quadriparesis and severe cognitive disability. Mutations
on one of six genes involved in nucleic acid repair have been implicated in the majority of cases,
with additional rare ade novoa autosomal dominant cases. Excessive interferon production results
in systemic inflammation and extensive end organ injury. Patients typically present with altered
mental status, including lethargy and irritability, feeding intolerance, and neurologic
abnormalities, such as loss of gross motor skills, seizures, or spasticity. Some patients may also
exhibit signs of systemic autoinflammation, such as fevers and skin involvement. There is evidence
of basal ganglia calcification, chronic cerebrospinal fluid (CSF) lymphocytosis, and elevated CSF
interferon type I. There are similarities and symptom overlap with systemic lupus erythematosus.
Overall, there is currently significant morbidity and high rate of mortality associated with this
syndrome. As a disorder of inappropriate immune activation, AGS has prompted interest in
immune-mediation therapies, including Janus kinase (JAK) inhibitors, reverse transcriptase
inhibitors, anti-IFN-alpha antibodies, anti-interleukin antibodies, antimalarial drugs, and other
cGAS inhibitors. Olumiant (baricitinib) is an oral JAK1/2 inhibitor that has been approved for
treatment of rheumatoid arthritis and has been used in case studies on patients with AGS.
Individual patients with AGS experienced decreased skin manifestations as well as improved
neurologic function following treatment with baricitinib.
This medication has not been approved by the U.S. Food and Drug Administration (FDA) in this
population, and the majority of articles cite the need for ongoing clinical studies, which are
particularly challenging given the heterogeneous nature of this disease. However, the FDA has
listed AGS as one of the conditions for which baricitinib can be used on a compassionate basis.
This medication is the only treatment available and is more likely to be beneficial than standard
therapy (symptomatic treatment only). Therefore, Olumiant 1 mg tablet is likely to be more
beneficial than other available standard therapy.
| [
"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:: | a8114bb1aeb33e4be9a8f42e66f9cb8b | ./data/processed/ca_cdi/summaries/20-7214.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
The parent of a one-year-old male enrollee has requested authorization and coverage for Olumiant
1 mg tablet. The Health Insurer has denied this request and reported that the requested medication
is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that AGS is a rare genetic neurological disease with onset in infancy. This patient has a mutation in the
SAMHD1 gene, one of the genes that has been noted to be associated with AGS. Meesilpavikkai
and colleagues described the successful treatment of chilblains in AGS patients with a SAMHD1
mutation and consequent uparegulation of type I interferon activity. JAK/STAT activation is
present in various autoimmune diseases, and treatment with specific JAK inhibitors in immunemediated
diseases has been increasingly reported. The oral JAK1/2 inhibitor baricitinib (Olumiant)
has been approved for the treatment of active rheumatoid arthritis. Vanderver and colleagues
recently reported that treatment of patients with AGS using baricitinib resulted in decreased skin
manifestations and improved neurological function. An ongoing phase II clinical trial of baricitinib
in AGS is on hold due to the coronavirus pandemic. There is no standard therapy available for
AGS. The syndrome is progressive. There appears to be a narrow window of opportunity for
effective intervention. The requested medication may arrest the progression of ongoing
inflammation and neurological deterioration. Therefore, Olumiant 1 mg tablet is likely to be more
beneficial than other available standard therapy.
| [
"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:: | a8114bb1aeb33e4be9a8f42e66f9cb8b | ./data/processed/ca_cdi/summaries/20-7214.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The parent of a 17-year-old female enrollee has requested authorization and coverage for mammoplasty, augmentation; with prosthetic implant (19325) and breast reconstruction with other technique (19366). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees breast hypoplasia. The physician reviewer found that based on the medical documentation provided for this review, this patient has a significant congenital breast deformity associated with asymmetric breast hypoplasia. This is supported by the medical documentation from the patients plastic surgeon, endocrinologist and review of the photographs. She has undergone a work-up for correctable causes and no cause, other than a congenital condition, has been found. Her appearance would not be considered relatively normal appearing breasts for a female. The breasts are severely asymmetric and hypoplastic. Therefore, attempts to approximate a more normal appearance should be considered reconstructive and not cosmetic surgery. This is consistent with medically necessary, reconstructive surgery (Sadove and van Aalst; Seyfer, et al). Further, the requested procedure is consistent with the recommendations from the American Society of Plastic Surgeons (ASPS). The ASPS notes that breast reconstruction surgery to correct breast deformities, as well as surgery on the contralateral breast to achieve symmetry, are considered reconstructive surgery and, therefore, should be a covered benefit and reimbursed by third-party payers. Therefore, breast augmentation for this patient should be considered congenital breast reconstruction and is therefore medically necessary. Given these findings, requested authorization and coverage for mammoplasty, augmentation; with prosthetic implant (19325) and breast reconstruction with other technique (19366) are supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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:: | 02310bc53af7a8a7052719f7b6f0fcb3 | ./data/processed/ca_cdi/summaries/18-6410.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The parent of a 15-year-old female enrollee has requested reimbursement for psychiatric residential treatment center (RTC) services from 5/13/15 through 12/31/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found upon review of the documentation provided, records from 5/13/15 through 12/31/15 show no evidence that the patients behaviors were out of control, or that the patient was psychotic or a danger to herself or others. Moreover, the records do not indicate that the patient required any special medical or nursing treatment that could not have been provided in a setting other than 24-hour level of care. The notes indicate normal therapy sessions that could have taken place if the patient were an outpatient rather than in a residential setting. The patient was generally cooperative and participated in therapy. She was not aggressive, combative, or incoherent. There is no documentation of particular treatment techniques that would have required an inpatient treatment setting. The patients psychiatrists notes consistently show that the patient was making good progress and that both Seroquel and lithium were no longer needed and were discontinued. Based upon the information stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| [
"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:: | ce0a944ad49f4172e5661fea01264ae5 | ./data/processed/ca_cdi/summaries/16-4568.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The parent of a five-year-old female enrollee has requested authorization and coverage for Tobii Dynavox T10 device and accessories. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollee, who has been diagnosed with cerebral palsy and receptive expressive language disorder. The physician reviewer found that the parent of a five-year-old female enrollee has requested authorization and coverage for Tobii Dynavox T10 device and accessories. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollee, who has been diagnosed with cerebral palsy and receptive expressive language disorder.
| [
"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:: | 2464879473824b213c99a96f15945c5a | ./data/processed/ca_cdi/summaries/17-4924.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested services in this clinical setting. The medical records document paroxysmal atrial fibrillation and a prior stroke with no documented significant bleeding complications on anticoagulation. In this circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting an increased bleeding risk, discontinuing anticoagulation while accepting an increased thromboembolic risk or percutaneous left atrial appendage exclusion using a Watchman device. The Watchman device has been demonstrated in one trial to be non-inferior compared with warfarin. However, device placement has a high rate of significant complications due to pericardial effusion and procedural stroke related to thromboembolism or air embolization. The Watchman device is not likely to be of greater benefit than other treatment options, especially in patients who are tolerating anticoagulation without significant bleeding side effects. 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:: | 20df2071e58cc8c4c1180c39c0e00460 | ./data/processed/ca_cdi/summaries/16-4455.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device). 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 current medical evidence supports the requested services in this patients case. The Watchman device is non-inferior to warfarin treatment for long-term stroke prevention due to paroxysmal or persistent atrial fibrillation. Given this patients recent thromboembolic stroke and known history of paroxysmal fibrillation, as well as higher bleeding risk for systemic anticoagulation, he is an appropriate candidate for the requested services. Therefore, the requested percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device) is likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 20df2071e58cc8c4c1180c39c0e00460 | ./data/processed/ca_cdi/summaries/16-4455.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device). 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 submitted documentation supports the requested services in this clinical setting. The left atrial appendage occlusion device (Watchman) has been approved to reduce the risk of thromboembolism from the left atrial appendage in patients with non-valvular atrial fibrillation, who are at increased risk for stroke and are recommended for anticoagulation therapy. There is sufficient support for the requested services in this patients case. Many patients with atrial fibrillation take warfarin or other blood thinning medicines to prevent a stroke caused by a blood clot in the brain. However, warfarin can increase the risk of bleeding anywhere in the body. If bleeding happens in the brain, this can also cause a stroke. In this patients case, the requested percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device) is likely to be more effective than other treatment options. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 20df2071e58cc8c4c1180c39c0e00460 | ./data/processed/ca_cdi/summaries/16-4455.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 68-year-old female enrollee has requested reimbursement for DecisionDX Melanoma Assay provided on 2/05/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees malignant melanoma. The physician reviewer found that the staging and prognosis of cutaneous malignant melanoma is classically determined by the system spelled out by Balch. There may be some further value in adding the mitotic rate to this system. As per this system, this patient would have been staged as a T1a melanoma, with an expected 10-year survival of at least 88%. There is no information in the records submitted as to whether she had sentinel node done, nor any clinical follow-up since her diagnosis in 2011. It is also not clear why this assay was ordered in February 2016 when her initial diagnosis was in 2011. DecisionDX Melanoma Assay is a study of 31 genes in melanoma cells. It then classifies that particular melanoma as either class 1 (with a 97% disease-free rate at five years) or class 2 (with a 31% disease free-rate at five years). It is not as yet clear how DecisionDX data compares to the ten-year data of the Balch determinations, and whether it can be used to make clinical practice decisions. This is particularly in question in this patients case given her pathologic findings and excellent prognosis. All told, DecisionDX Melanoma Assay provided on 2/05/16 was not medically indicated for the treatment 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:: | c27f6c8c90c9cfde427f02cc92ed66a9 | ./data/processed/ca_cdi/summaries/17-4899.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The patient is a 23-year-old female with a history of limited cutaneous systemic sclerosis, Raynauds phenomenon, mild skin tightness, arthritis and gastrointestinal disease. Per the provider, the patient has been treated with sildenafil since 2010 with good results. On 11/20/17, she presented for follow-up. She was to have repeat pulmonary function testing given her worsening shortening of breath and follow-up with subspecialty providers. She continued to have mild depigmentation in her anterior shins, increased dilated blood vessels at the medial ankle, Raynauds at fingers and cold feet. The patients therapies included hydroxychloroquine, methotrexate, pantoprazole, calcium/vitamin D, inhalers and sildenafil. Examination demonstrated mild sclerodactyly, dilated purple ankle vessels at the left ankle, right fourth finger periungual dilation, light tan ill-defined patches on both shins, and multiple blue dilated vessels on left lateral thigh. The plan is to increase sildenafil to, follow-up with gastroenterology, continue Plaquenil, and consider hematology consultation for possible iron infusion. Prior treatment has included nifedipine, Imuran, methotrexate, Rituximab, and Dynacirc without improvement, as well as minocycline. Pulmonary function testing on 12/31/14 showed restrictive chest wall disease, with potential airway disease and an increase in resistance. Echocardiogram on 6/29/16 showed a normal left and right ventricle and systolic function, with no significant change from previous study on 6/26/15. The patient has requested authorization and coverage for sildenafil 20 mg tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary. For the treatment of secondary Raynauds phenomenon, the treatment of choice is a calcium channel blocker. Second-line treatment is typically a phosphodiesterase inhibitor (PDE-5). Roustit and colleagues concluded that PDE-5 inhibitors appear to have significant but moderate efficacy in secondary Raynauds phenomenon. Thompson and colleagues reported that PDE-5 medications are able to reduce episodes by 0.5/day which is comparable to calcium channel blockers (CCB) reduction by 0.6/day. In this case, the patient has failed multiple medications to include methotrexate, Imuran, CCB, Dynacirc, and Rituximab. The medical records demonstrate response with sildenafil. All told, the requested sildenafil 20 mg tablets is supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| [
"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:: | 3b048ce4cbd841cefc67b0b5cca980e6 | ./data/processed/ca_cdi/summaries/18-6511.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 2/6/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was not likely to be more effective for this patient than other available options. Prometheus Anser IFX Test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions, as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. Some evidence exists that low serum levels of infliximab or adalimumab or the presence of IFX or ADA antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. In sum, there is a lack of sufficient evidence in the peer-reviewed literature to establish the testing at issue 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 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:: | 03be66442295f12fcb10f2f3d29e06b7 | ./data/processed/ca_cdi/summaries/16-4365.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 2/6/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was likely to be more effective for this patient than other available options. Therapeutic drug monitoring for infliximab and antibodies to the drug is appropriate for optimizing the treatment of the patients who are being treated with Remicade. The loss of response to infliximab can be due to subtherapeutic infliximab levels or the presence of antibodies to infliximab, and performing this assay can be very useful in the management of the patients with ulcerative colitis who are being treated with infliximab. The concept of dose adjustment, based on drug levels, has several potential benefits, one of which is that providers could not only increase drug doses in patients with subtherapeutic drug levels, but could also reduce drug doses in patients with supertherapeutic levels, thereby making the treatment safe for the patients. Therefore, measuring both IFX and ATI concentrations may help guide patient management, optimize care, prevent complications, and reduce long-term morbidity and mortality from complications. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 03be66442295f12fcb10f2f3d29e06b7 | ./data/processed/ca_cdi/summaries/16-4365.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 2/6/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the patient has left sided ulcerative colitis disease and has been maintained on Remicade since August 2013. However, she had incomplete response as documented clinically despite being maintained on Remicade. Hence, in the midst of this course, while on adequate therapy, an IFX test was ordered to check for Remicade that would necessitate considering alternate therapy. Thus, the indication for the IFX test was the patients ulcerative colitis and incomplete response being on adequate treatment with Remicade and ruling out alternate causes complicating this course. In this case, the IFX test was indicated due to the multitude of management options once a patient has no response to Remicade and the fact that Remicade has a wide array of adverse effects, it is important for the treating provider to have a roadmap of the nature of the patients clinical course. Therefore, the Prometheus Anser IFX testing performed on 2/6/14 was likely to be more beneficial for evaluation and treatment of the patients ulcerative colitis than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 03be66442295f12fcb10f2f3d29e06b7 | ./data/processed/ca_cdi/summaries/16-4365.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
An 18-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavioral analysis (ABA) therapy provided from 9/12/16 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 autism. The physician reviewer found that ABA therapy is a medically appropriate intervention for the treatment of autism spectrum disorders, and remains one of the most evidence-based interventions available. In this case, the patient has a diagnosis of autism with repetitive, restricted and/or stereotypic behaviors. The patients maladaptive behaviors interfere with his activities of daily living, making it difficult for him to be successful in more generalized environments. ABA therapy has been recommended for treatment of the patients daily living skills in the areas of independent living, job skills, community skills, self-injurious behaviors, aggression and stereotypical behaviors. Moreover, the provider also recommends training for the parents, and other family members and caregivers that are involved in the patients care. The training is to be focused on increasing independent skills while fading direct and indirect prompts required to complete tasks. Based on the clinical documentation submitted for review, ABA therapy provided from 9/12/16 forward was and is medically necessary for treatment of the patients autism. 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:: | beebcc1fb5c6ee645535986b2188d167 | ./data/processed/ca_cdi/summaries/17-4934.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 60-year-old female enrollee has requested reimbursement for Prolia (denosumab) injection administered on 10/20/15. The Health Insurer has denied this request indicating that the medication at issue is considered investigational for treatment of the enrollees osteoporosis.The physician reviewer found scienific studies reveal that osteoporosis is an increasingly widespread condition, affecting 55% of Americans aged 50 and above. Of these, approximately 80% are women. Fractures are the most dangerous aspect of osteoporosis. They can lead to acute and chronic pain as well as increased mortality (Old and Calvert). A newer medication, denosumab (Prolia) is a fully human monoclonal antibody which has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone (McClung, et al). Studies support the use of Prolia for the treatment of postmenopausal women with osteoporosis who are at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapies. This patient met medical necessity criteria for Prolia, as she failed other anti-resportive therapies for her osteoporosis. Therefore, the medication at issue was likely to be more efficacious in treatment of the patients osteoporosis than any available standard of therapy. Based upon the information set forth above, the medication at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | e6a0c0059be2f93096ff5234bbc1015c | ./data/processed/ca_cdi/summaries/16-4550.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 60-year-old female enrollee has requested reimbursement for Prolia (denosumab) injection administered on 10/20/15. The Health Insurer has denied this request indicating that the medication at issue is considered investigational for treatment of the enrollees osteoporosis. The physician reviewer found upon review of the medical record, Prolia was likely to be more efficacious in treating the patients medical condition than any available standard therapy. A substantial amount of medical evidence exists to support Prolia as an appropriate treatment option for patients with osteoporosis. Furthermore, Prolia has received Food and Drug Administration approval for the treatment of osteoporosis. The patient has documented osteoporosis with a history of fracture. The DEXA scan of the patients hip and spine demonstrate treatment with Prolia. In sum, the second injection of Prolia in October 2015 was beneficial for treatment of this patients osteoporosis.Based upon the information set forth above, the medication at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | e6a0c0059be2f93096ff5234bbc1015c | ./data/processed/ca_cdi/summaries/16-4550.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 60-year-old female enrollee has requested reimbursement for Prolia (denosumab) injection administered on 10/20/15. The Health Insurer has denied this request indicating that the medication at issue is considered investigational for treatment of the enrollees osteoporosis. The physician reviewer found Prolia is approved by the Federal Drug and Administration for treatment of postmenopausal osteoporosis. It is anticipated that Atelvia will not provide the benefit of therapy given that the patient has poor absorption and her bone density has not improved in the hip. The patient has severe osteoporosis as documented by a BMD below -3 in both femoral necks and prior peripheral fracture. The patients medical records indicate that she is at a high risk for fracture and studies have shown that Prolia reduces the incidence of vertebral fractures by about 68%, hip fractures by about 40%, and nonvertebral fractures by about 20% over 3 years (Cosman et al). Moreover, the patient was on bisphosphonate (Atelvia) therapy and her BMD did not improve. The patient also has a history of gluten intolerance, which suggests that she might have a malabsorption factor, which makes oral bisphosphonates poorly absorbed and therefore ineffective. For all these reasons, the medication at issue was likely to be of more benefit for treatment of the patients osteoporosis than available standard therapy. Based upon the information set forth above, the medication at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | e6a0c0059be2f93096ff5234bbc1015c | ./data/processed/ca_cdi/summaries/16-4550.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The patient is a 61-year-old female who presented to her provider on 5/25/21 with a complaint of worsening knee pain. The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee. The physician reviewer found that the current medical evidence does not support the requested services in this clinical setting. The incidence of abnormal MRI findings in asymptomatic individuals was established as early as 1992 by Boden and colleagues. The authors noted, aThe high incidence of abnormal MRI findings in asymptomatic subjects underscores the danger of relying on a diagnostic test without careful correlation with clinical signs and symptoms.a In other words, simply obtaining an MRI without correlation with a detailed clinical examination can lead to unnecessary conclusions, and even worse, unnecessary surgery. For this reason, conservative management, as suggested by the Health Insurer, is certainly worthwhile. In the requisition for the knee MRI, it is stated that the patient has had four weeks of prior physical therapy as well as supervised home exercise program within the prior three months. However, the records do not document this. The submitted documentation does not demonstrate that the patient has completed an appropriate course of conservative management. The records do not document that the patient actually underwent physical therapy. Absent this documentation, the medical necessity of the requested services cannot be established. Therefore, the requested MRI of the left knee is not medically necessary for the evaluation of this patient. | [
"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:: | d6090aaf23cc0b4de6ec0dfffa53490f | ./data/processed/ca_cdi/summaries/21-7378.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The patient is a 58-year-old female with osteoporosis of the spine demonstrated on a recent dual-energy x-ray absorptiometry (DEXA). She also has history of hypothyroidism, hypercholesterolemia and breast cancer that has been treated with letrozole. Her provider has recommended Prolia. The patient has requested authorization and coverage for Prolia injection. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The submitted documentation supports the medical necessity of the requested medication. This patient has osteoporosis of the spine. Her risk factors include postmenopausal status, treatment with letrozole, an aromatase inhibitor, and vitamin D deficiency. This patient needs to initiate osteoporosis therapy. This patient is on Synthroid, thyroid hormone replacement, which she must take on an empty stomach. This requirement will be affected by the requirement to take alendronate on an empty stomach as well. Additionally, zoledronic acid is frequently associated with a flu-like syndrome post injection, whereas Prolia has rare side effects. Per the medical evidence, Prolia has a better outcome in prevention of spinal fractures as compared to oral bisphosphonates. There is sufficient support for the requested medication in this clinical setting. Thus, the requested Prolia injection is medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| [
"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:: | 0d4a9640c3474963594119d061c155df | ./data/processed/ca_cdi/summaries/18-6280.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 48-year-old male enrollee has requested authorization and coverage for intravenous immune globulin (IVIG). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees specific antibody dysfunction. The physician reviewer found the treatment of specific antibody deficiency with replacement immunoglobulin remains controversial. Most experts recommend treatment which includes immunization with conjugated pneumococcal vaccine (Prevnar 7 or 13), aggressive treatment of other conditions predisposing to recurrent sinopulmonary infections, increased vigilance and appropriate antibiotic therapy for infections, prophylactic antibiotics and IVIG. Replacement IGIV is an option for patients with proven recurrent infections that persist after immunizing with conjugate vaccines and appropriate antibiotic treatment (Cohn, et al.). However, studies have demonstrated that prophylactic antibiotic therapy may be as effective as replacement immunoglobulin (Gelfand, et al). In this case, the patient is not on an antihistamine for his elevated IgE and there is no evaluation of his most likely allergic component to his symptoms. The patient has not been vaccinated with the conjugate pneumococcal vaccines. There is also no documentation of a trial of prophylactic antibiotics. Moreover, IVIG is a pooled blood product and there are significant risks involved in the administration of IVIG including thrombosis, renal dysfunction, acute failure and infection. The documentation does not support that IVIG is safe and effective for the patient. In addition, there is no documentation other therapies used and failed such as aggressive allergic rhinitis treatment, vaccinated with conjugate pneumococcal vaccine or trial of prophylactic antibiotics in the patient. Therefore, the request for IVIG is not medically necessary in this clinical setting. For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| [
"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:: | e281103cbf098eeffca14024c9365160 | ./data/processed/ca_cdi/summaries/15-4250.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 33-year-old male enrollee has requested authorization and coverage for CPT code 27299 (unlisted procedure, pelvis/hip joint). The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees hip pain. The physician reviewer found that surgical hip dislocation is an established technique for addressing both articular and periarticular pathology associated with painful femoral acetabular impingement. This patient has extensive labral tearing and degeneration including posterior which would be difficult or impossible to treat arthroscopically. Periacetabular osteotomy and labral repair cannot be performed open without dislocating the hip. Thus, dislocation of the femoral head is necessary to access and treat the acetabular sided pathology. Given these findings, the requested CPT code 27299 (unlisted procedure, pelvis/hip joint) is supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| [
"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:: | 73045de427b7b3df65968bacf5c4902e | ./data/processed/ca_cdi/summaries/18-6404.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 51-year-old male enrollee has requested authorization and coverage for inpatient care. The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees surgical procedure. The physician reviewer found that infection of a penile implant can cause complications from scarring after the penile implant is removed. Although a few studies with a small numbers of patients have shown that penile implants can be done in an outpatient setting, most providers prefer to continue preoperative antibiotics for at least 24 hours. The American Urological Associations (AUA) guideline for management of erectile dysfunction states, These antibiotics are administered before the incision is made and usually are continued for 24 to 48 hours postoperatively. The AUA best practice statement for antimicrobial prophylaxis in urologic surgery states, Although there are no [randomized controlled trials] RCTs regarding antimicrobial prophylaxis for insertion of penile prostheses, meta-analyses of mesh hernia repair 100 and orthopedic surgery 101 confirm that antimicrobial prophylaxis is beneficial when foreign material is implanted. A prolonged course of antimicrobials has been used by many practitioners following penile prosthesis insertion, but evidence from the orthopedic literature suggests that prophylaxis for 24 hours or less is adequate. In this case, there is a lack of documentation to support the medical necessity for inpatient care. Most patients who undergo penile prosthesis implantation can be discharged within 24 hours of presentation. The patient can be provided with perioperative antibiotics while on observation status without the need for inpatient stay. As such, the request for inpatient admission is not medically necessary for treatment of the patients medical condition. Therefore, the requested service 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:: | 085f31d60c2688fd560629555d2fc409 | ./data/processed/ca_cdi/summaries/17-6081.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 57-year-old female enrollee has requested reimbursement for code 81599 (DecisionDx-Melanoma) testing provided on 1/29/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network 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. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there are no definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, code 81599 (DecisionDx-Melanoma) testing provided on 1/29/19 was 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:: | 90e806fe45fed9e98f142d965225d9f4 | ./data/processed/ca_cdi/summaries/19-6849.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The patient is a 42-year-old female with a history of chronic low back pain. The progress notes dated 10/7/17, document a six month history with pain in the lower back radiating into both lower extremities. Associated symptoms included numbness, tingling and loss of bladder/bowel control. The pain was reported to be 8 out of 10 and worsening. The patient reported that any level of movement aggravated her low back pain. Medications for pain relief were not effective. Other conservative treatments, which have been tried and failed, include chiropractic, physical therapy, topical, and exercise program. On examination, transfers were difficult; range of motion was limited and magnetic resonance imaging (MRI) scan revealed degenerative disc disease at L5-S1 with a 2 mm bulge and possible annular tear on the right. The follow up progress notes document continuing worsening of pain, primarily in the lower back on the right side consistent with the MRI findings of the right side involvement. The provider discussed treatment options and the patient elected the surgical option in light of the degree of disability. The provider is recommending anterior lumbar interbody fusion at L5-S1 with anterior instrumentation, L5-S1 cage with interbody fusion with harvest of iliac crest autograft versus bone morphogenic protein. The patient has requested authorization and coverage for autograft spine surgery. The Health Insurer denied this request and reported that the requested services are not medically not necessary. This denial is the subject of this appeal and determination. There is support in the medical literature for the medical necessity of the requested services in this clinical setting. Anterior lumbar interbody fusion is associated with higher success 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 patients with 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. With regard to the type of interbody spacer used, the proposed autograft has a high fusion rate. In this case, the patient has severe pain that has not responded to conservative treatment. The patients pain is interfering with her activities of daily living. The provider has documented discogenic origin for the pain. Based on medical literature and guidelines, the requested anterior lumbar interbody fusion procedure is medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, 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:: | b14b573a2a5a81375496d72fce1198b0 | ./data/processed/ca_cdi/summaries/18-6240.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The parent of a 14-year-old male enrollee has requested reimbursement for residential mental health treatment services provided from 4/25/16 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 attention deficit hyperactivity disorder (ADHD). The physician reviewer found that the records provided for review do not support the medical necessity of residential mental health treatment services provided from 4/25/16 through 12/31/16 for management of this patients medical condition. There was no evidence that the patient had severe and persistent psychiatric symptoms that results in impairment in multiple settings that require active treatment in a 24-hour supervised setting. Further, there was no evidence of suicidal or homicidal ideations, no evidence of psychosis, and no evidence of physical aggression during this period of time. The documentation suggests the patient could have reasonably been treated at a less intrusive, less invasive level of care such as outpatient treatment. Given these findings, the residential mental health treatment services provided from 4/25/16 through 12/31/16 were not medically necessary. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| [
"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:: | 2d3141c7972c24e362f8af7446c4c4c1 | ./data/processed/ca_cdi/summaries/16-4778.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 63-year-old male enrollee has requested reimbursement for dopamine transporter imaging with a single proton emission computed tomography (DaT SPECT) scan performed on 8/24/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who presented with persistent hand tremors. The physician reviewer found that there is sufficient support in the medical literature for the services at issue. While a DaT SPECT study is not required for the diagnosis of all patients suspected to have Parkinsons disease, it has been shown to be useful in cases where the diagnosis is not definitive on clinical grounds. In this particular case, the patients provider suspected Parkinsons disease, although by the history an essential tremor would have been an alternative diagnosis. It is imperative to provide a definitive diagnosis as treatment for essential tremor and Parkinsons disease are quite different. The treatment options for Parkinsons disease can have significant side effects. This patients diagnosis was determined and verified using this study. As such, an appropriate management approach was initiated. The literature demonstrates the use of this study in differentiating cases of Parkinsons and essential tremor. An improper diagnosis could have led to suboptimal management and potential exposure to unnecessary side effects. Therefore, DaT SPECT scan performed on 8/24/16 was likely to have been superior to other methods of evaluating this patients medical condition. Based upon the information set forth above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 134894f6aa7578e318aa1c35427e76d7 | ./data/processed/ca_cdi/summaries/17-4920.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 63-year-old male enrollee has requested reimbursement for dopamine transporter imaging with a single proton emission computed tomography (DaT SPECT) scan performed on 8/24/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who presented with persistent hand tremors. The physician reviewer found that DaT is an acceptable diagnostic technique for the determination of Parkinsons disease. In patients where the cause of tremor is not known or is likely to be caused by other diagnoses, such as essential tremor, the use of a DaT scan can be helpful in determining the correct diagnosis. This scan has been widely used by movement disorders specialists and general neurologists when there is a question of whether a patient has Parkinsons disease. Medical studies have shown that the early diagnosis of Parkinsons disease allows for better control of symptoms and allows the patient to access available resources sooner. Accordingly, this patient benefited significantly from having the scan performed in order to confirm the cause of his tremor. All told, DaT SPECT scan performed on 8/24/16 was likely to have been more effective than other available modalities in evaluating this patient. Based upon the information set forth above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 134894f6aa7578e318aa1c35427e76d7 | ./data/processed/ca_cdi/summaries/17-4920.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3A 63-year-old male enrollee has requested reimbursement for dopamine transporter imaging with a single proton emission computed tomography (DaT SPECT) scan performed on 8/24/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who presented with persistent hand tremors. The physician reviewer found that there is a lack of evidence based studies supporting the superior efficacy of the services at issue. The medical literature does not demonstrate that DaT SPECT scan can offer clinical decision making relative to treatment management options in this clinical setting. There remains issues of sensitivity and specificity relative to DaT scans in the diagnosis of Parkinsonian tremor versus other etiologies. Therefore, in this patients case, DaT SPECT performed on 8/24/16 was not likely to be more efficacious than other standard options for the evaluation of this patient. Based upon the information set forth 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:: | 134894f6aa7578e318aa1c35427e76d7 | ./data/processed/ca_cdi/summaries/17-4920.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The parent of 10-year-old female enrollee has requested authorization and coverage for growth hormone treatment. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees growth hormone deficiency. The physician reviewer found that although combination therapy with GnRH agonist and GH is not recommended for augmentation of height in children with normally timed puberty or in children with idiopathic short stature alone. This patient has a combination of early adrenarche with advanced skeletal maturation at baseline, coupled with true central precocious puberty resulting in rapid acceleration in skeletal maturation and an extremely short adult predicted height. Her adult height prediction is more than three standard deviations below the mean for age, and her epiphyses are still open. Her skeletal maturation is outpacing her statural growth, resulting in a shorter adult height prediction over time. Based on a recent meta-analysis, evaluating the efficacy and safety of combination therapy with GnRH agonist and GH in children with central precocious puberty, children with combination therapy reached a taller adult height and larger height gains without adverse effects (Liu, et al). As such, GH therapy is medically necessary in this patient to achieve a normal adult height. Therefore, for the reasons stated above, 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:: | 4318214f402f176fa94e5fb49e36c1b7 | ./data/processed/ca_cdi/summaries/18-6160.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer A 55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found that the staging and prognosis of cutaneous malignant melanoma is classically determined by the system spelled out by Balch and colleagues. There may be some further value in adding the mitotic rate to this system. As per this system, this patient was staged as T1a, melanoma, with no mitoses seen. This would have an expected ten year survival of at least 88%. There is no information in the records submitted as to whether she had sentinel node performed. DecisionDX, melanoma assay is a study of 31 genes in melanoma cells. It then classifies that particular melanoma as either class 1 (with a 97% disease-free rate at five years) or class 2 (with a 31% disease free-rate at five years). It is not clear how DecisionDX data compares to the ten year data of the Balch determinations, and whether it can be used to make clinical practice decisions. This is particularly in question in this patients case given her pathologic findings and excellent prognosis. All told, DecisionDX-melanoma laboratory testing performed on 5/13/16 was not likely to have been more effective than other modalities for evaluating this 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:: | 426367fd14ce7e1b067ae82b0deeb8b0 | ./data/processed/ca_cdi/summaries/17-4907.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found that a commercial gene expression profile test (DecisionDX-Melanoma) 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, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. Per the National Comprehensive Cancer Network (NCCN) 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 (baseline) genetic testing of primary cutaneous melanomas is not recommended. At this time, the gene test performed on 5/13/16 was not likely to be of greater benefit than available standard therapy for the evaluation of this 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:: | 426367fd14ce7e1b067ae82b0deeb8b0 | ./data/processed/ca_cdi/summaries/17-4907.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found that the diagnostic test DecisionDX melanoma test is considered experimental. The test, using retrospective data, helps determine the risk of recurrence for early melanoma. The test lacks therapeutic implications as there is limited published data to support using adjuvant therapy in early stage I and II melanoma (lymph node negative) regardless of risk of recurrence. Furthermore, prospective randomized data for determination of risk of recurrence is lacking for this test. The scientific evidence does not support the superior efficacy of this test over standard options available for evaluation of patients in this clinical setting. Moreover, there is a lack of evidence that this technology improves the net health outcome. As such, the DecisionDX-melanoma laboratory testing performed on 5/13/16 was not likely to have been more efficacious than other options available for 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:: | 426367fd14ce7e1b067ae82b0deeb8b0 | ./data/processed/ca_cdi/summaries/17-4907.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
The parent of a 17-year-old male enrollee has requested reimbursement for residential treatment at Arivaca Boys Ranch from 5/26/16 through 2/13/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting. Based on national guidelines, at the time of admission, the patient could have received services at a lower level of care. 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. On 5/26/16, the patient met the following criteria prior to admission to the residential treatment facility. The patients score for risk of harm was a 1, which translates to low risk. Per the documentation, the patient had no history of suicide attempts. He did not have any suicidal ideation at the time of admission. He was screened at the RTC and was determined to be a no safety risk. The patients functional status was a 3, which is a moderate functional impairment due to a very conflictual relationship with his parents. The patient has been tardy to school and there were concerns that if his behavior continued, disciplinary actions would be taken by the school. His comorbidity was also scored as a 3, which correlates to a significant comorbidity. Additionally, the patient had a comorbidity related to his diagnoses of oppositional defiant disorder, attention deficit hyperactivity disorder, and marijuana abuse. The patients substance abuse was having a significant adverse effect on his functioning. However, the patient appeared to be medically stable and did not have any medical conditions that required 24 hour monitoring. With regard to his recovery environment, his score is a 2, which relates to a mildly stressful environment. The patients parents were supportive. However, there was conflict in the home due to expectations from the parents and/or from the school. The conflict led to arguments and contributed to his oppositional behavior. The patients score with regard to his environmental support was a 2, because both parents were supportive. As for his score in the area of resiliency and treatment, the patient had limited ability to deal with stressors. He demonstrated a limited ability to follow through with recommendations from his prior outpatient therapist. As such, his score in the area of equivocal resiliency and response to treatment was a 3. He also scored a 3 in the area of acceptance and engagement at the time of admission. The patient did not want to be in care. However, it appears from the notes, the patient was able to develop positive relationships with the providers during his RTC stay. In sum, according to the CALOCUS scoring system, this patients composite score at the time of admission was 17. The patient required treatment for his marijuana abuse, ODD, and ADHD, but his treatment could have been performed at a less restrictive environment like in an intensive outpatient program. It is standard of care to treat the patient in the least restrictive environment possible. Moreover, it was noted that the patient reported to the RTC staff that he wished to be treated in a less restricted environment. Based on the CALOCUS system as well as peer reviewed medical literature, this patient could have been treated in a less restricted environment. Therefore, residential treatment at Arivaca Boys Ranch from 5/26/16 through 2/13/17 was not medically necessary for treatment of this patient.
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:: | 2990a9539e3ba8f55407f85630a1f6e5 | ./data/processed/ca_cdi/summaries/17-6040.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 54-year-old female enrollee has requested reimbursement for inpatient hospitalization provided from 3/31/17 through 4/07/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who sustained injuries when she fell off a horse. The physician reviewer found that this patient presented status post a traumatic fall from a horse resulting in severe back pain. Clinical examination findings were consistent with imaging evidence of L1 and L3 acute compression fractures. She had severe pain that was not controlled with oral medications. She was admitted for inpatient care for pain control and observation on 3/31/17. She was placed on bed rest with bracing ordered. She continued to require intravenous medication due to inadequate relief with oral medications. She was very limited in her activity due to severe pain. Given the failure of closed treatment with bracing and continued severe pain with associated functional limitations, she underwent L1 and L3 vertebroplasty on 4/04/17. Following this procedure, she was able to ambulate with physical therapy, and oral pain medications provided adequate control as of 4/07/17. She was discharged to home on 4/07/17 with home health services. Evidence-based medical guidelines support hospitalization for parental narcotics and inability to manage basic activities of daily living at home, and additionally support a three-day best practice length of stay following vertebroplasty. Continued inpatient stay is supported until acceptable patient status for the next level of care is achieved, including pain is adequately managed on oral medications, and activity levels are at baseline or acceptable. Therefore, inpatient hospitalization provided from 3/31/17 through 4/07/17 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. | [
"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:: | f853bc0f826bae3e46cf7b6a7ba7bb46 | ./data/processed/ca_cdi/summaries/18-6444.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
I have determined that the services at issue were 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. The physician reviewer found that the patient is a 53-year-old male who complains of lumbar pain that started in 2012 after hot yoga. He had increasing back pain on and off over the last several years and has tried two facet injections, with no relief. The patient reported that a zero gravity chair is beneficial, and Kenalog injections reportedly provide temporary relief. The patient has requested reimbursement for mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.
The current medical evidence has not demonstrated the superior efficacy of the services at issue. There is a lack of support for continuous or intermittent traction as a single treatment for patients with low back pain with and without sciatica. Clarke and colleagues noted, traction for patients with sciatica cannot be judged effective at present either, due to inconsistent results and methodological problems in most studies. Therefore, mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18 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:: | 634ad3e23f23e03efc1bf7d162927661 | ./data/processed/ca_cdi/summaries/18-6481.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
I have determined that the services at issue were 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. The physician reviewer found that the patient is a 53-year-old male with a history of low back pain. He received mechanized spinal distraction therapy for his low back pain. On 4/25/18, the patient reported that a zero gravity chair helps. The patient took gabapentin at night, and Kenalog injections reportedly provided temporary relief. Significant objective findings included no ataxia and no shuffling gait, intact cranial nerves, and 2+ reflexes in the upper and lower extremities. Based on the letter dated 7/19/18, the patient reported that he has tried acupuncture and physical therapy. He has requested reimbursement for mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.
Research does not show that lumbar traction is likely more beneficial for the patients condition compared to any available standard therapy. Schimmel and colleagues found that there was no difference between the Intervertebral Differential Dynamics Therapy and sham therapy 14 weeks after the start of the treatment neither for primary outcome nor for the secondary outcome. Both groups reported a significant improvement in low back pain, leg pain, and daily function. Thackeray and colleagues showed that patients with lumbar nerve root compression presenting for physical therapy can expect significant changes in disability and pain over 6-week treatment period and there is no evidence that mechanical lumbar traction in combination with an extension-oriented treatment is superior to extension-oriented exercises alone in the management of these patients. In sum, mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18 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:: | 634ad3e23f23e03efc1bf7d162927661 | ./data/processed/ca_cdi/summaries/18-6481.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
I have determined that the services at issue were 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. The physician reviewer found that the patient is a 53-year-old male who presented for a course of treatment on 4/25/18 for the diagnosis of lumbosacral intervertebral disc displacement. It was noted that the patients lower back pain began in 2012 after a hot yoga class. Prior treatment reportedly included facet joint injections. On 4/26/18, the patient began a course of mechanized spinal distraction therapy. He has requested reimbursement for mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.
There is a lack of support for the services at issue in this clinical setting. The records document a history of low back pain. The patients prior treatment included facet joint injections. Additionally, he has tried acupuncture and physical therapy. The medical literature has not demonstrated that mechanized spinal distraction therapy is superior over standard modalities for the treatment of this patient. Thus, mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18 was not likely to have been more effective than other treatment options. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 634ad3e23f23e03efc1bf7d162927661 | ./data/processed/ca_cdi/summaries/18-6481.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 1
A 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination. The physician reviewer found that there is evidenced base support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to be more effective than had her examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 75d6902e4ff74d35bff700cc510a5712 | ./data/processed/ca_cdi/summaries/17-4917.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination. The physician reviewer found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, her breasts have been described as extremely dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis performed on 9/26/16 was likely to have been of greater benefit than other modalities for evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.]
| [
"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:: | 75d6902e4ff74d35bff700cc510a5712 | ./data/processed/ca_cdi/summaries/17-4917.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination. The physician reviewer found that there is sufficient support for digital breast tomosynthesis in the evaluation of this patient. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening. Based upon the information set forth above, the service at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 75d6902e4ff74d35bff700cc510a5712 | ./data/processed/ca_cdi/summaries/17-4917.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 20-year-old male enrollee has requested authorization and coverage for residential substance use disorder treatment from 2/9/16 through 3/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The patient presented with a CIWA score of 1 which is consistent with having mild withdrawals. By 2/9/16, he was not a danger to himself or others. He was medically and psychiatrically stable. He did not require a detoxification protocol. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant a residential treatment services level of care. The psychiatric evaluation indicated that his impulse control appeared to be good. He was motivated and appeared to be working the program. Given his recent residential experience in August 2015, he had an educational exposure to relapse prevention, coping skills, and the 12 step program. His family was supportive in his efforts. He did not require the 24 hour structure of residential and could have safely been treated at an ambulatory level of care such as an intensive outpatient program. As such, the residential substance use disorder treatment from 2/9/16 through 3/10/16 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:: | bacce3ad7211e811fd853a4deccf038a | ./data/processed/ca_cdi/summaries/16-4742.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 55-year-old female enrollee has requested authorization and coverage for corticotropin (Acthar Gel). The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. This patient has not exhausted all other possible therapies for rheumatoid arthritis, and the medical records do not clearly document that the patient has failed each therapy reported to have been tried and failed. Acthar Gel has not been proven to be superior to alternative therapies, such as prednisone or methylprednisolone, in terms of efficacy or safety for the long-term management of rheumatoid arthritis. Since Acthar Gel exerts at least some of its anti-inflammatory effects through corticotrophin receptors, Acthar Gel carries the same potential risks as steroids, including diabetes.
H.P. Acthar has a corticotropin effect and with that, the same potential side effect profile as steroids with respect to osteoporosis, glaucoma, cataracts, weight gain, increased blood pressure, and glucose intolerance. Therefore, corticotropin (Acthar Gel) is 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:: | 25d61261cdadffd7542c1e735803ca00 | ./data/processed/ca_cdi/summaries/19-6940.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 55-year-old female enrollee has requested authorization and coverage for corticotropin (Acthar Gel). The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the records document refractory rheumatoid arthritis and type 2 diabetes. She has tried and failed multiple medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), high-dose intravenous corticosteroids, methotrexate, Enbrel, Arava, Plaquenil, Rituxan, Actemra, Xeljanz, Cimzia, Humira, Orencia, Imuran, Simponi, and Remicade. She has failed multiple tumor necrosis factor inhibitors and multiple biologic agents and continues to have active rheumatoid arthritis. In this case, the use of Acthar Gel would not be considered off-label, as Acthar Gel is approved for short-term use in rheumatological conditions, and this request is for six to eight weeks of therapy. She would need to be bridged to another medication. Short-term use would be consistent with current labeling and as a bridge to more definitive therapy. In sum, corticotropin (Acthar Gel) is 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:: | 25d61261cdadffd7542c1e735803ca00 | ./data/processed/ca_cdi/summaries/19-6940.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 55-year-old female enrollee has requested authorization and coverage for corticotropin (Acthar Gel). The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has been diagnosed with rheumatoid arthritis and has been treated with multiple medications, including anti-inflammatory drugs (NSAIDs), high-dose intravenous corticosteroids, methotrexate, Arava, Xeljanz, Actemra, and Orencia. Per the treating provider, she has developed either side effects to the tried medications or has not responded sufficiently in terms of disease activity to the medications. Acthar Gel is not a recommended treatment for rheumatoid arthritis. Furthermore, there is a paucity of objective data to support that the patient has had an inadequate response to other evidenced-based medications that have been tried previously. Per the last included treatment note from September 2019, objective findings included synovitis at one joint that was chronic, and no significant deformities of any joint. The submitted documentation fails to support the requested medication in this clinical setting. Thus, corticotropin (Acthar Gel) is 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:: | 25d61261cdadffd7542c1e735803ca00 | ./data/processed/ca_cdi/summaries/19-6940.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 63-year-old male 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 chronic hepatitis C virus genotype 1a. The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. Due to thrombocytopenia, this patients provider noted that he is not a candidate for treatment with interferon. All told, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. In sum, 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:: | 267e74174911457dd10c939843538561 | ./data/processed/ca_cdi/summaries/15-4168.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 37-year-old female enrollee has requested reimbursement for the Afirma thyroid fine needle aspiration (FNA) analysis provided on 1/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pituitary tumor and elevated prolactin. The physician reviewer found that
the National Comprehensive Cancer Network (NCCN) indicated that genetic profiling for atypia of unknown significance is a category 2b recommendation. In the medical literature, Duick and colleagues reported that obtaining a gene expression classifier in patients with cytologically indeterminate nodules is associated with a striking reduction in the rate of diagnostic thyroidectomy. Thus, in conjunction with peer-reviewed literature, the Afirma thyroid analysis performed on 1/15/15 was likely to have been more beneficial for thorough evaluation of this patients condition than any available testing.
Based upon the information set forth above, I have determined the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | b25c1ed0cd1637a5fc347cff56b84138 | ./data/processed/ca_cdi/summaries/15-4283.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 37-year-old female enrollee has requested reimbursement for the Afirma thyroid fine needle aspiration (FNA) analysis provided on 1/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pituitary tumor and elevated prolactin. The physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was consistent with cancer was via surgical excision (Miller, et al). The Afirma thyroid FNA analysis from Veracyte utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because the Afirma thyroid test is very sensitive and has a high negative predictive value, a negative result is suggestive of a benign nodule (Duick, et al). Given this support, the Afirma thyroid FNA analysis provided on 1/15/15 was likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | b25c1ed0cd1637a5fc347cff56b84138 | ./data/processed/ca_cdi/summaries/15-4283.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 37-year-old female enrollee has requested reimbursement for the Afirma thyroid fine needle aspiration (FNA) analysis provided on 1/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pituitary tumor and elevated prolactin. The physician reviewer found that Thyroid nodules are commonly managed by diagnostic FNA to evaluate the cytopathology. In this case, the finding by this standard technique was atypia of undetermined significance (Baloch, et al). This diagnostic category creates a dilemma with regards to recommended surgery. In this case, the patient was facing total thyroidectomy if malignancy was present and but only subtotal thyroidectomy if the lesion turned out to be benign. Hence, the sample was submitted to Veracyte for gene expression analysis. The Afirma gene expression test conducted by Veracyte has demonstrated a very high negative predictive value for malignancy (Alexander, et al; Chudova, et al). All told, the current peer-reviewed medical literature supports the diagnostic utility of the Afirma thyroid FNA analysis provided on 1/15/15 as likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned. | [
"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:: | b25c1ed0cd1637a5fc347cff56b84138 | ./data/processed/ca_cdi/summaries/15-4283.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the U.S. Food and Drug Administration (FDA) has approved the LINX Reflux Management System for the treatment of lower esophageal sphincter augmentation. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter (LES) closure pressure, but allow for food passage with swallowing. Reynolds and colleagues performed a study comparing the LINX procedure with laparoscopic fundoplication was performed which used propensity matching to compare groups. The authors found that GERD patients had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. In addition, a five-year cohort data was recently published establishing the durability of LINX. In a group of 85 patients augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux with minimal side effects or complications. Given the support cited above, the LINX procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Based upon the information set forth above, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | c23b9d512176f22c07c20f3ac076e39d | ./data/processed/ca_cdi/summaries/16-4754.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for GERD, it is critical to document the presence of abnormal distal esophageal acid exposure, especially when anti-reflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach. Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery (Jobe, et al). In this case, the patient has undergone much of this pre-operative assessment but clinically significant reflux has not been demonstrated. In addition, the value of the LINX device in this clinical setting is uncertain. The patients pH recording demonstrated normal DeMeester scores (off acid blocker therapy) and her video esophagram did not show active reflux. Further, her infrequent reflux events proved poorly correlative with chest symptoms, thus, her ongoing symptoms cannot be considered medically refractory to acid blocker drugs. Also, implantation of the LINX device must be approached with caution given the patients documented complaint of dysphagia and demonstrated hang-up of a barium pill on esophagram. All told, the request for 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 procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | c23b9d512176f22c07c20f3ac076e39d | ./data/processed/ca_cdi/summaries/16-4754.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found there is a lack of randomized controlled trials comparing Linx with Nissen fundoplication or other standard surgical anti-reflux procedures. According to Sheu and Rattner the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. In addition, Loh and colleagues concluded that further studies are required to determine its long term outcomes and its relative efficacy as compared to other established treatments, Adverse events, such as erosion through the esophagus, have been reported since U.S. Food and Drug Administration (FDA) approval (Bauer, et al). The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, such as surgical fundoplication. Based on current literature and clinical guidelines, LINX 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 procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | c23b9d512176f22c07c20f3ac076e39d | ./data/processed/ca_cdi/summaries/16-4754.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 64-year-old male enrollee has requested reimbursement for inpatient stay at telemetry level of care provided from 5/23/18 through 5/30/18. 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 at the time of admission, the patient had a low potassium and an elevated troponin level. He had multiple cardiac risk factors, including hypertension, diabetes mellitus, congestive heart failure and advanced renal disease. Given these risk factors and the severity of his infection and wounds, it was reasonable to admit him to a telemetry level of care for 24 hours. The initial 24 hours is sufficient time to check serial echocardiogram and cardiac enzymes and have a cardiology consultation. Furthermore, the potassium level was improved by 5/24/18. He did not have any chest pain or acute ischemia on admission, and after monitoring and serial enzymes/echocardiograms, he could have been treated at a lower level of care from 5/25/18 through 5/30/18. Therefore, inpatient stay at telemetry level of care provided from 5/23/18 through 5/24/18 was medically necessary for the treatment of this patient. The records fail to demonstrate the medical necessity of inpatient stay at telemetry level of care provided from 5/25/18 through 5/30/18. | [
"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:: | 5b930c1d249cb7e65891b856f483f8d6 | ./data/processed/ca_cdi/summaries/19-6796.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The parent of a 17-year-old female enrollee has requested reimbursement for surgery performed on 6/22/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollees enlarged labia. A review of the record indicates that the enrollee presented to her provider on 4/27/17. The enrollee reported enlarged labia which caused her to wear panty liners daily so that the bulge would not be noticeable through her underwear. Due to pad usage, she developed chronic irritation with intermittent vaginal discharge. On 6/22/17, bilateral labia minora reduction was performed. The Health Insurer indicates that the services at issue were not medically necessary. Therefore, the Health Insurer has denied reimbursement for the services at issue. At issue is whether the services at issue were medically necessary for treatment of the enrollees medical condition. I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. 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:: | 2511270f9c3865c51c00bf7beda75374 | ./data/processed/ca_cdi/summaries/18-6228.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes. The physician reviewer found that based on the records provided the patient is a 60-year-old female with infrequent syncope recently resulting in head trauma and negative short-term evaluation for culprit arrhythmias. In this setting, prolonged monitoring for a dysrhythmic cause of the patients syncope is reasonable, appropriate and considered standard accepted practice in the medical community. Prolonged monitoring cannot be feasibly obtained with any monitoring device other than an implantable device such as a LINQ monitor. This approach has shown to be more effective than standard monitoring in identification of a cause and is now incorporated into current guidelines (Strickberger, et al; Krahn, et al; Brignole, et al). Therefore, the request for a heart monitor (implantable ambulatory event monitor) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | eb40b7dacb12384521952a8b46cf2523 | ./data/processed/ca_cdi/summaries/17-6024.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes. The physician reviewer found the request for a LINQ device is likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. The patient has been extensively evaluated with two Zio Patch event monitoring periods in 2016 and 2017, neither of these studies demonstrated an etiology for recurrent syncope. In addition the patient has a structurally normal heart as well as a negative electrophysiologic study which failed to demonstrate inducible arrhythmias or periods of high grade atrioventicular block. In light of these facts other than an implanted loop recorder there is no other diagnostic modality that would likely be more helpful. As such, request for a heart monitor (implantable ambulatory event monitor) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | eb40b7dacb12384521952a8b46cf2523 | ./data/processed/ca_cdi/summaries/17-6024.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes. The physician reviewer found the request for a heart monitor (implantable ambulatory event monitor) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The ILR is a non-invasive diagnostic device that is often of great clinical use in this clinical setting, since it can remain in place for long periods of time and provide information about arrhythmias when other techniques have not been revealing. In this case, the patient has syncope with head trauma and previous evaluation has not determined the cause of syncope. The patients symptoms are described as infrequent and the extensive work-up was performed years. The requested device is likely to provide better information than a 30-day monitor or any other type of monitor currently available. Moreover, the use of the ILR is in accordance with American College of Cardiology guidelines. For the reasons provided, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | eb40b7dacb12384521952a8b46cf2523 | ./data/processed/ca_cdi/summaries/17-6024.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain. The physician reviewer found the request for radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is medical literature supporting the utility of radiofrequency neurolysis in this clinical setting. In addition, the patient was previously treated with radiofrequency ablation which provided pain relief which lasted almost 11 months. As such, the request for radiofrequency neurolysis 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 service 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:: | e6c7390c866043a27a379965a2256056 | ./data/processed/ca_cdi/summaries/17-5004.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain. The physician reviewer found the medical literature recommends using a pain diary to verify when the local anesthetic wore off for the treatment of diagnostic medial branch block prior to radiofrequency ablation (Derby, et al). According to the documentation available for review, the records do not document a pain diary. Moreover, it is unclear that she obtained significant benefit from the prior radiofrequency ablation. The record submitted does not support that she did obtain relief to corroborate improvement, with no mention of increased functional benefit from a baseline or decrease in perceived pain from a baseline. Therefore, the request for radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | e6c7390c866043a27a379965a2256056 | ./data/processed/ca_cdi/summaries/17-5004.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain. The physician reviewer found the radiofrequency ablation is an accepted treatment that can be included in the standard of care when treating chronic back pain. The patient has symptoms consistent with facet mediated pain and has undergone prior radiofrequency ablation. She continues to perform an independent home exercise program and is limited in terms of medication tolerance. Recent imaging showed an improvement in the previous L5-S1 disc herniation consistent with the time since previous imaging as well as the patients commitment to exercise and conservative treatments. The two-level right-sided procedure proposed is supported by the patients reported symptoms. The patient had a positive response to radiofrequency ablation performed in December 2015. The current request for repeat radiofrequency ablation is more than six months after the prior treatment. Based on the clinical documentation submitted for review, the requested service 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 service 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:: | e6c7390c866043a27a379965a2256056 | ./data/processed/ca_cdi/summaries/17-5004.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 54-year-old male has requested reimbursement for genetic testing performed on 2/04/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that Foundation One assay is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay would identify a specific target which could inform the clinician as to what chemotherapeutic agent would be useful. Thus far, however, there is a lack of convincing evidence that the assay adds to the decision-making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have offered convincing evidence of the efficacy of this approach. A randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular assay versus by the oncologists clinical judgment. The demonstration of a mutation on assay does not guarantee that a drug targeted at the mutation will be useful. In sum, genetic testing performed on 2/04/16 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:: | 0ae2398149c743014df8224bdee74066 | ./data/processed/ca_cdi/summaries/18-6170.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 54-year-old male has requested reimbursement for genetic testing performed on 2/04/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer.The physician reviewer found that Foundation One testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis other than KRAS, NRAS, and BRAF mutations. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. Per the medical evidence, Foundation One testing was unlikely to be more beneficial than any available standard therapy such as testing the tumor for standard markers, such as KRAS, NRAS, and BRAF. All told, genetic testing performed on 2/04/16 was not likely to have been superior over other available methods of evaluating this patient. Based upon the information set forth above, the services at issue were 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:: | 0ae2398149c743014df8224bdee74066 | ./data/processed/ca_cdi/summaries/18-6170.jsonl | Insurer Denial Upheld | Experimental |