text
stringlengths 1
26.3k
| tags
sequencelengths 4
5
| date_accessed
stringclasses 1
value | source_url
stringclasses 5
values | source_md5
stringlengths 32
32
| relative_path
stringlengths 35
82
| decision
stringclasses 12
values | appeal_type
stringclasses 29
values |
|---|---|---|---|---|---|---|---|
Summary Reviewer 3
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 patients with refractory or relapsed cancer that have exhausted standard treatments are usually considered for clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues performed a study of 86 patients where the progression-free survival on the regimen selected by molecular profiling was compared to the progression-free regimen on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. Genetic testing may be highly informative. For example, KRAS and BRAF mutations may inform therapy decisions. KRAS is one of the most frequently mutated oncogenes in colorectal cancer (35-45% of patients). The gain of function mutations most commonly occur in codon 12 or codon 13. In several clinical trials, mutation in KRAS is associated with worse progression-free survival compared to patients with wild type KRAS when treated with monoclonal antibody directed against EGFR in combination with chemotherapy. In one large randomized clinical trial where FOLFIRI was tested with or without Erbitux, KRAS mutation status did not significantly affect progression-free survival. There is published data from a large retrospective trial that the presence of the BRAF mutation provides additional prognostic information with regards to cetuximab treatment. The MEK kinases are within the same pathway as RAS and BRAF. Mekinist or trametinib is a new inhibitor of MEK kinases approved for use in metastatic melanoma with mutant BRAF. In this patients case, the results from molecular profiling offers a rational selection of the next regimen. Thus, genetic testing performed on 2/04/16 was likely to have been more efficacious than other standard 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:: | 0ae2398149c743014df8224bdee74066 | ./data/processed/ca_cdi/summaries/18-6170.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 1
A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.The physician reviewer found in this case, the medical records fail to indicate any diagnosis consistent with an IgG mediated food allergy to support an indication for the testing at issue. The current National Institutes of Health National Institute of Allergy and Infectious Disease expert panel states that IgG food testing is not validated (Boyce, et al). The Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated (Sampson, et al). As such, IgG food testing is not considered the standard of care in this clinical setting (Sicherer and Teuber). Thus, the IgG food sensitivity testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | b496a7a25558383321a679429d366ad7 | ./data/processed/ca_cdi/summaries/16-4609.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort. The physician reviewer found based on the current literature and guidelines that address IgG diagnostic testing, IgG food sensitivity testing is not considered a clinically useful, relevant, or valid method for evaluation of abdominal discomfort, or for identifying food allergy or food intolerance that may be contributing to abdominal discomfort or other gastrointestinal symptoms. IgG and IgG subclass antibody tests for food allergy related conditions do not have clinical relevance and lack sufficient quality control, and should not be performed (Boyce, et al). All told, the IgG food sensitivity testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | b496a7a25558383321a679429d366ad7 | ./data/processed/ca_cdi/summaries/16-4609.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort. The physician reviewer found the use of food-specific IgG level testing has not been shown to improve health outcomes at long-term follow-up. There is data suggesting that this testing does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods (Beyer and Teuber). Thus, food-specific IgG should not be used as a tool to diagnose food allergy and the positive foods should not be eliminated from the diet based upon results of these tests (Lemon-Mule, et al; Savilahti, et al). The standard evaluation of food allergy consists of blood IgE level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum. Immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens including egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95%. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. A negative skin test result indicates the absence of an IgE-mediated allergy upon subsequent challenge with a 90 to 95% predictive accuracy. In conclusion, the IgG food laboratory testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard of care.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:: | b496a7a25558383321a679429d366ad7 | ./data/processed/ca_cdi/summaries/16-4609.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 1
A 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral corneal ectasia. The physician reviewer found that there is sufficient support for the superior efficacy of the services at issue in this patients case. Collagen crosslinking procedure has been well studied as a treatment option for corneal ectasia and to stabilize vision loss. Based on the patients vision loss and progression, crosslinking was the most appropriate and effective treatment available. The services at issue are not considered experimental. Instead, crosslinking is validated by the medical literature findings. There is a large body of evidence demonstrating that this treatment is safe and effective for post refractive ectasia. This includes recent prospective placebo controlled trials with a large number of patients that demonstrate the effectiveness of stabilizing corneal ectasia and potentially delaying or preventing the need for full thickness corneal transplant. Furthermore, corneal collagen crosslinking for corneal ectasias fulfills an unmet need. There is very few treatment options available to slow or halt disease progression. As such, treatment for this patients condition with collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16 was likely to have been more effective than any other available option for this patient. 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:: | 82dd397158fb1bf8c7202e37e714bca5 | ./data/processed/ca_cdi/summaries/17-6082.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral corneal ectasia. The physician reviewer found that Corneal crosslinking is a U.S. Food and Drug Administration (FDA) approved procedure for corneal ectasia and post refractive ectasia. The primary purpose of crosslinking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus and post refractive corneal ectasia. The procedure involves soaking the corneal stroma with riboflavin and then using ultraviolet light to create chemical bonds between collagen fibrils within the stroma. This stiffens the cornea and halts the thinning. Prior to this treatment, patients with keratoconus who failed medical treatment (glasses, contact lenses) and whose disease continued to progress would go on to surgical management with corneal transplantation. There have been multiple studies published which demonstrate that patients who underwent corneal crosslinking showed an improvement in keratometry values, uncorrected visual acuity and best corrected visual acuity in contrast to sham group. Of note, this procedure is not considered a refractive or vision correcting as the primary purpose of crosslinking is to stabilize the cornea and prevent further thinning and bulging that is seen with keratoconus and post refractive ectasias. In addition, there have been studies that have shown an overall decrease in the number of penetrating keratoplasties performed since the introduction of crosslinking. There is mounting evidence of the benefit of this treatment in patients diagnosed with keratoconus and post refractive ectasias who have progressive disease. Given the patients topographic evidence of post refractive ectasia, as well as the evidence of progressive disease, collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16 were likely to have been superior over any other methods for treatment of this patients medical condition. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 82dd397158fb1bf8c7202e37e714bca5 | ./data/processed/ca_cdi/summaries/17-6082.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral corneal ectasia. The physician reviewer found that the medical literature supports the efficacy of the services at issue in this clinical setting. Collagen crosslinking is a standard treatment for progressive keratoconus and ectasia after refractive surgery. It was approved by the U.S. Food and Drug Administration in 2016. There are many case series showing the efficacy in post Lasik ectasia. In order to determine if a patient is an appropriate candidate for collagen crosslinking, one must have evidence of progression, which can be based on refraction, keratometry, topography, or objective testing measures. In this patients case, the records from the patients provider noted evidence of progression. Given the likelihood of progression, collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16 were likely to have been the most effective treatment option for this patient.
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:: | 82dd397158fb1bf8c7202e37e714bca5 | ./data/processed/ca_cdi/summaries/17-6082.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 43-year-old transgender female enrollee has requested authorization and coverage for electrolysis epilation, each 30 minutes. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found the requested services are within accepted standard of practice and clinically appropriate for treatment of this patients gender dysphoria. In this case, the patient is well-documented to have gender dysphoria; thus, her external anatomy should be more consistent with a female than a male. She has transitioned into living as a female since she began hormone therapy in 2013. The requested epilation hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible. Moreover, the requested treatment may improve emotional function in this patient. It would create a more feminine genital or extremity appearance. The medical literature support the services at issue for treatment of gender dysphoria. 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:: | 1427831191eeb07434b6ed4995c5aa12 | ./data/processed/ca_cdi/summaries/16-4601.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 35-year-old female enrollee has requested authorization and coverage for surgical jaw reconstruction. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the medical necessity for the requested surgical jaw reconstruction has not been established in this clinical setting. The patient presents with a class II malocclusion and has been recommended to undergo orthodontic appliances and double jaw surgery. However, a clear functional deficit related to this malocclusion that has failed reasonable conservative management and would likely improve with complex surgical intervention has not been adequately defined in the medical documentation. The patient complains of discomfort and intermittent pain. However, it is not clear from the requesting surgeon that this is from the malocclusion and that this would likely improve with surgical correction, as he states that this may or may not improve with jaw repositioning and correction of her occlusion. In addition, based on the photographs, the patient does not have evidence of significant disfigurement from her malocclusion and overjet. Therefore, the requested procedures are not considered medically necessary, as there is not a well-defined functional impairment that would likely improve with surgical intervention. Moreover, based on the photographs submitted for review, the patient does not have evidence of significant deformity to warrant surgical correction on a reconstructive basis.
Therefore, 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:: | 5a3542cae30af29596c1a5b335988ac2 | ./data/processed/ca_cdi/summaries/16-4368.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 32-year-old female enrollee has requested reimbursement for prenatal testing performed on 1/10/14. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees suspected fetal abnormality. The physician reviewer found, while cell-free fetal DNA testing is a very effective screening test for women at high risk for fetal trisomy, the use of this test for lower risk women has not been established. The American Congress of Obstetricians and Gynecologists (ACOG) currently states Given the performance of conventional screening methods, the limitations of cell-free DNA screening performance, and the limited data on cost-effectiveness in the low-risk obstetric population, conventional screening methods remain the most appropriate choice for first-line screening for most women in the general obstetric population. Since this patients risk of Down syndrome at the time of testing was appropriately assessed as 1:5,000, she would not be classified as at high-risk for fetal trisomy. The data underlying this recommendation comes from the Non-Invasive Chromosomal Evaluation (NICE) Study that only included patients with an increased risk of fetal aneuploidy, with a presumed prevalence of trisomy 21 of 1:50 in their cohort. More recent studies on cell-free DNA testing in a low risk or routine population has confirmed [cell-free DNA] cfDNA testing was superior to that of traditional first-trimester screening for the detection of trisomy 21 in a routine prenatal population, but indicates further study is still needed (Norton, et al (2015). 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:: | b2d1a61998d477d3f642538d4e1e05d9 | ./data/processed/ca_cdi/summaries/15-4111.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 32-year-old female enrollee has requested reimbursement for prenatal testing performed on 1/10/14. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees suspected fetal abnormality. The physician reviewer found in this case, the prenatal cell-free DNA screening provided on 1/10/14 was likely to be more beneficial than other modalities. The patients 18-week ultrasound revealed two soft markers associated with an increased risk of aneuploidy. The American College of Obstetricians and Gynecologists Committee on Genetics recommend women regardless of maternal age be offered cell-free DNA who present with ultrasonographic findings indicating an increased risk of aneuploidy. This patient presented with ultrasound markers associated with an increased risk of aneuploidy. As such, the testing at issue was likely to be more beneficial than other modalities. 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:: | b2d1a61998d477d3f642538d4e1e05d9 | ./data/processed/ca_cdi/summaries/15-4111.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 32-year-old female enrollee has requested reimbursement for prenatal testing performed on 1/10/14. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees suspected fetal abnormality. The physician reviewer found non-invasive prenatal testing uses cell-free fetal DNA from the plasma of pregnant women to detect trisomy 13, 18 or 21 (Sparks, et al.). The American College of Obstetrics and Gynecology has recommended that women, regardless of maternal age, be offered prenatal assessment for aneuploidy either by screening or invasive prenatal testing. Cell-free DNA is now another option that can be used as a primary screening test in women at an increased risk of aneuploidy. Increased risk women include maternal age 35 years or older with fetal findings indicating an increased risk of aneuploidy. In this case, the patient was at an increased risk of aneuploidy, given the fetal ultrasound findings indicating an increased risk of trisomy. The patients anatomic screen demonstrated two soft signs, and for this reason the cell-free DNA screening was clinically indicated and likely to be more beneficial for evaluation of the patients medical condition. 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:: | b2d1a61998d477d3f642538d4e1e05d9 | ./data/processed/ca_cdi/summaries/15-4111.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 24-year-old male enrollee has requested reimbursement for Rituxan provided on 12/17/18. The Health Insurer has denied this request and reported that the medication at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that pediatric autoimmune neuropsychiatric disorder is a term used to describe a patient with OCD or tic disorders which are made worse by group A streptococci. The association between pediatric autoimmune neuropsychiatric disorder and group A streptococci is controversial. Furthermore, the idea that pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS) is an autoimmune disorder is controversial. Immune modulating treatment is not routinely recommended. The treatment of choice for OCD includes cognitive-behavioral therapy, a selective serotonin reuptake inhibitor medication, or both. In this case, the patient has diagnoses of schizophrenia, OCD and PANDAS. Rituximab is an antineoplastic agent, monoclonal antibody immunosuppressant agent. It is not approved by the U.S. Food and Drug Administration for the treatment of OCD, schizophrenia or PANDAS. Therefore, Rituxan provided on 12/17/18 was not medically necessary for the treatment of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | a786c0ef0625e6264f9179f8a94ab7e9 | ./data/processed/ca_cdi/summaries/19-6779.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 26-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by the staging system spelled out by Balch. Mitotic index is thought to add a bit to these statistics. DecisionDx-Melanoma testing is an assay of the molecular and genetic changes in an individualas melanoma cells. It then classifies that melanoma based on the five-year risk of metastasis. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not known if DecisionDx-Melanoma data can be used to make clinical decisions, such as whether to do a sentinel node or not. Therefore, DecisionDx-Melanoma testing performed on 4/15/19 was not likely to have been 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:: | e82cbd1d56b595bb61991b832614f8b1 | ./data/processed/ca_cdi/summaries/21-7231.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 26-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that various (mostly retrospective) studies of prognostic gene expression profiling (GEP) testing suggest its role as an independent predictor of worse outcome, although not superior to Breslow thickness or sentinel lymph node status. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models. Therefore, DecisionDx-Melanoma testing performed on 4/15/19 was not likely to have been more beneficial than other available standard therapy.
| [
"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:: | e82cbd1d56b595bb61991b832614f8b1 | ./data/processed/ca_cdi/summaries/21-7231.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 26-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Therefore, DecisionDx-Melanoma testing performed on 4/15/19 was not likely to have been 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:: | e82cbd1d56b595bb61991b832614f8b1 | ./data/processed/ca_cdi/summaries/21-7231.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
The parent of a seven-year-old male enrollee has requested reimbursement for a tonsillectomy and adenoidectomy performed on 10/27/15. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees recurrent strep throat. The physician reviewer found that this case involves justification of the surgical intervention performed on the patient because of recurring episodes of acute pharyngitis and tonsillitis with positive cultures and requirements for antibiotic therapy. Tonsillectomy and adenoidectomy is a well-recognized surgical procedure for the treatment of patients with episodes of recurring acute pharyngitis and tonsillitis poorly controlled with outpatient antibiotic therapies. Multiple case studies have demonstrated that surgical removal of the infected source of the Streptococcal infections by removal of the tonsils and adenoids leads to improvement and reduction of the episodes of these acute infections (Baugh, et al). Clinical studies also indicate that patients who have multiple bouts of Streptococcus positive cultures, such as the patient in this clinical scenario, benefit from surgery to reduce the recurrence of these episodes (Burton, et al). This patient had clear documentation of recurrent episodes of culture positive pharyngitis and tonsillitis. Therefore, the tonsillectomy and adenoidectomy performed on 10/27/15 was medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the surgery at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | aac2a2fd94faf803e6b1f03b85bc604e | ./data/processed/ca_cdi/summaries/16-4661.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 51-year-old female enrollee has requested authorization and coverage for Sovaldi and ribavirin. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 2b. The physician reviewer found that due to the approval and availability of new therapies, clinical guidelines and accepted standards of care were completely revised in late 2014. 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 genotype 2, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Additionally, treatment of patients before they progress to F3 or F4 fibrosis is advantageous. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested Sovaldi and ribavirin are medically necessary for treatment of this patients medical condition. Consistent with these findings, 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:: | 9390017a5ff9b21b2cb34239d9f5d667 | ./data/processed/ca_cdi/summaries/15-4175.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 43-year-old female enrollee has requested reimbursement for residential treatment center services provided from 5/27/17 through 6/26/17. The Health Plan 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 based on the Level of Care Utilization System (LOCUS) criteria, as of 5/27/17, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is two (2), low risk of harm. The patient does not have any prior history of suicide attempts. On admission, the patient did not have any suicidal ideation. The patient was able to care for herself. The patient did not have any legal problems. The patients functional status score is three (3), moderate impairment. The patients substance use led her to lose her job. She was unable to fulfill responsibilities and obligations in her job. The patients medical, addictive and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of alcohol use disorder, depression, migraine headaches, and hypertension. The patients recovery environment score is two (2), mildly stressful environment. The patient is single and has two children, ages 10 and 13. Potential for alcohol exposure exists at her home. The patients level of support score is two (2), supportive environment. The patients parents are supportive of the patient. The patient also has community support in Alcoholics Anonymous. The patients treatment history score is three (3), moderate response to treatment and recovery. The patients prior treatments have been modestly successful. She had obtained five months of sobriety prior to the residential treatment center admission. The patient also had 70 days of sobriety while receiving treatment as an outpatient. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient was motivated for recovery and cooperative with staff. She would accept and participate in treatment. Based on these criteria, the patient had a total score of 17 and met criteria for an intensive outpatient program (IOP). Therefore, the residential treatment center services provided from 5/27/17 through 6/26/17 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:: | caca91ca2aef55ca5d2624373aabfd0a | ./data/processed/ca_cdi/summaries/17-6068.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 50-year-old male enrollee has requested authorization and coverage for Repatha SureClick. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypercholesterolemia. The physician reviewer found that Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient does not fit either of those criteria. The presence of coronary calcium does not equate to coronary obstruction, and there is no documented obstructive coronary stenosis or clinical cardiovascular disease, such as stroke, myocardial infarction, angina, ischemia on stress testing, or prior coronary revascularization. PCSK9 inhibitors have not been adequately studied in other patient populations, such as this patient with an elevated calcium score but no documented clinical cardiovascular disease. The current guidelines do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Thus, Repatha SureClick is not medically necessary for the treatment of this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | [
"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:: | 074df102b68398dc22d3fc7186f4b21e | ./data/processed/ca_cdi/summaries/18-6490.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The parent of a 16-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services provided from 1/31/17 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that the records provided for review do not support the medical necessity criteria for RTC services from 1/31/17 forward for treatment of this patients behavioral health issues. The patient did not demonstrate behaviors suggesting that he was at imminent risk of harm to self or others. The patients psychiatric issues prompting admission could have been safely and efficiently been treated at a less intensive setting. The patient has also not shown to have any acute impairment in behavior or issues with cognition that interfered with activities of daily living. Psychosocial and environmental problems were not likely to threaten the patients safety and did not undermine engagement at a less intensive level of care, such as outpatient care. All told, the patient did not require 24-hour supervision and management at the RTC level of care from 1/31/17 forward. Based on the foregoing discussion, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 0e60005c72fc787abd6f2d6fe5b324c0 | ./data/processed/ca_cdi/summaries/17-4987.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The parent of a five-year-old male enrollee has requested reimbursement for albendazole provided on 3/01/18. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees medical condition.The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue. This patient does not have documented parasitic infection. There is some use of albendazole in children on the autistic spectrum that have gastrointestinal issues, but in the absence of positive cultures, this would be considered off-label usage and not consistent with the current standard of care. The medical evidence does not support the medication at issue in this clinical setting. Therefore, albendazole was not medically necessary in this patients case. Therefore, the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld. | [
"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:: | ac168676c982311c420b1f15ccc02d05 | ./data/processed/ca_cdi/summaries/18-6471.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 49-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma assay provided on 2/14/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. While the majority of clinical stage I patients will be disease-free at five years, some stage I patients will develop advanced disease. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx-Melanoma assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 consistent with a low risk of metastasis or Class 2 suggestive of a high risk of metastasis. One peer-reviewed publication indicated that there was a statistically significant association of a Class 1 signature by DecisionDx-Melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently Class 2 (Sidiropoulos, et al). The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. According to the results of analysis of this patients melanoma performed with DecisionDx-Melanoma assay, the tumor was classified as Class 1 with a low risk of near-term (within five years) metastatic disease. Therefore, DecisionDx-Melanoma signature may be an independent predictor of metastasis risk. However, there is a lack of peer-reviewed published studies confirming this hypothesis. Accordingly, the DecisionDx-Melanoma assay performed on 2/14/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 10c3648498bf18c731db0d9588adb92d | ./data/processed/ca_cdi/summaries/18-6169.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 49-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma assay provided on 2/14/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma gene assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma assay provided on 2/14/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 10c3648498bf18c731db0d9588adb92d | ./data/processed/ca_cdi/summaries/18-6169.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 49-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma assay provided on 2/14/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx-Melanoma assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. The test has not been demonstrated to provide a beneficial effect on health outcomes. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a greater benefit beyond that anticipated with established tests, the DecisionDx-Melanoma assay provided on 2/14/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 10c3648498bf18c731db0d9588adb92d | ./data/processed/ca_cdi/summaries/18-6169.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 33-year-old female enrollee has requested reimbursement for DecisionDX melanoma gene expression profiling assay. 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 the submitted documentation fails to demonstrate the medical necessity of the services at issue. In this clinical setting, at least a 95% five-year survival and an 88% ten-year survival is predicted based on staging described by Balch and mitotic index. DecisionDX is a study of 31 genes in the melanoma cells. It then classifies that particular melanoma as either Class 1 (97% disease-free rate at five years) versus Class 2 (31% disease-free rate at five years). Per the medical evidence, there is good correlation between prognosis and DecisionDX classification. However, it is not clear how DecisionDX data compares to the ten-year data of the Balch determinations, and whether it can be used in clinical practice. This is significant in this patients case given her pathologic findings and excellent prognosis. This assay was not expected to be of clinical benefit in this case. All told, DecisionDX melanoma gene expression profiling assay 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:: | e4b7569565597ff6d2f6487a219348ff | ./data/processed/ca_cdi/summaries/15-4205.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The parent of a 17-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment provided from 6/28/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Psychiatric Association treatment guidelines for eating disorders recommend either an inpatient unit or residential treatment facility when lower levels of care have been tried and failed. Additionally, the presence of comorbid conditions is an important factor to consider when deciding on the appropriate level of care. This patients comorbidities include major depressive disorder with suicidal ideation. Brewerton and Costin noted that for patients with anorexia nervosa there were statistically significant improvements in mean body mass indexThe great majority of patients completing treatment showed significant improvement at discharge from intensive residential treatment. This patient is experiencing a disturbance in mood, affect or cognition resulting in disordered eating behavior that could not be safely managed in a less restrictive setting. Therefore, residential treatment is in accordance with generally accepted standards of medical practice. Thus, mental health residential treatment from 6/28/19 forward was and is medically necessary for the treatment of this patient. | [
"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:: | e80391534037238c2ff1499fb532c726 | ./data/processed/ca_cdi/summaries/19-6787.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 44-year-old female enrollee has requested reimbursement for positron emission tomography (PET) scan performed on 3/04/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting. Assessment of the response to treatment of metastases is crucial in daily oncological practice and clinical trials. For soft tissue metastases, this is done using CT scanning, magnetic resonance imaging (MRI) or PET scanning using validated response evaluation criteria. While PET/CT scanning may not be indicated when the recent CT scans or MRI scans are positive, this is less convincing when the recent CT or MRI scans are negative. In this patients case, the negative CT scans of the chest, abdomen, and pelvis were a reasonable indicator that the patient does not have metastatic disease. However, breast carcinoma often spreads to the bones, and the bones had not been specifically evaluated. PET/CT scans offer the ability to image the entire body as opposed to routine CT scans which must be directed to specific body regions. This patient is at a high-risk for developing metastatic disease, and a baseline PET/CT scan may help to further direct or continue what will be a second-line chemotherapy. All told, the PET scan performed on 3/04/16 was medically indicated for the evaluation of this patient. Therefore, the services at issue were 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:: | 4bd7f3bbf3d1d25c3eb654871a536f56 | ./data/processed/ca_cdi/summaries/16-4523.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the services at issue in this patientas case. Beckmann and colleagues concluded that their results asupport the clinical application of arthroscopic arthroplasty as a procedure that enhances cartilage repair as an alternative to far more complex procedures that have gained popularity. Furthermore, the data presented supports clinical investigations that recommend not to use suction drainage as by this procedure a considerable amount of the regeneratory potential of postoperative joint effusions might be extracted.a Lubowitz concluded, aArthroscopic abrasion arthroplasty results in a positive outcome in 66% of patients, and may still merit consideration as a salvage procedure.a This patient presented with a history of right medial meniscus tear and a significant loose body in the lateral gutter, resulting in mechanical locking. She had arthritic changes in the knee for which an arthroplasty might be indicated. However, her primary concern was mechanical locking. Surgery was performed on 8/16/19 to include right knee arthroscopy with partial medial meniscectomy, removal of a large intra-articular body, and abrasion chondroplasty for to the undersurface of the patella for grade III and IV chondral wear. Current evidence-based medical literature supports the inclusion of abrasion chondroplasty (CPT code 29879) during concurrent medial meniscectomy and loose body removal for mechanical locking and to potentially delay total knee replacement given her relatively young age and documented grade III to IV chondral wear. Therefore, arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19 was likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
| [
"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:: | b4db7c965d2cc1c20cacfb264018b3c2 | ./data/processed/ca_cdi/summaries/20-7106.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the role of arthroscopic debridement in the painful degenerative knee is controversial. Studies have shown that arthroscopic surgery for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. However, there are some exceptions to this rule. Patients with symptomatic meniscal tears and degenerative changes in the knee can benefit from arthroscopic meniscectomy, particularly if they are having mechanical symptoms such as locking. Similarly, a large loose body causing mechanical symptoms should be removed, even in the presence of osteoarthritis. Loose body removal has been proven to be more effective than conservative treatment for knee osteoarthritis. Therefore, the partial medial meniscectomy and loose body removal were medically necessary. The third procedure is abrasion chondroplasty, which has been denied. The role of arthroscopic debridement in the painful degenerative knee is controversial. Abrasion chondroplasty consists of shaving of fibrillated loose articular cartilage with a mechanical shaver. Studies have shown that such arthroscopic debridement for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. As such, arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19 was not likely to have been more beneficial for treatment of the patientas medical condition than any 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:: | b4db7c965d2cc1c20cacfb264018b3c2 | ./data/processed/ca_cdi/summaries/20-7106.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the American Academy of Orthopaedic Surgeons (AAOS) published clinical practice guidelines on osteoarthritis of the knee. The guidelines noted, aWe cannot recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.a Kirkley and colleagues published their results on a prospective randomized trial of patients with moderate to severe knee osteoarthritis that were treated with knee arthroscopy. The authors concluded, aArthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy.a These results were further supported by Mosely and colleagues who showed that athe outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.a In this case, the patient was being treated for knee osteoarthritis. There is no evidence of an appropriate course of non-operative treatment. There were no submitted radiology reports for knee x-rays or a knee magnetic resonance imaging (MRI). While removal of the loose body was necessary to improve mechanical symptoms to the knee, the abrasion chondroplasty for the treatment for knee osteoarthritis and degenerative joint disease is not supported by the current AAOS guidelines. Thus, arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19 was not likely to have been more beneficial for treatment of the patientas medical condition than any 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:: | b4db7c965d2cc1c20cacfb264018b3c2 | ./data/processed/ca_cdi/summaries/20-7106.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 19-year-old male enrollee has requested reimbursement for wilderness treatment program services provided from 10/23/18 through 1/16/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. With regard to risk of harm, the records support a score of 4. The patient had serious risk of harm due to a recent pattern of excessive substance use resulting in loss of self-control and harmful behaviors with no demonstrated ability to abstain from use. In terms of functional status, the records support a score of 3. The records documented a need for a leave of absence from school due to substance abuse, as well as recent gains in sobriety achieved in a structured setting. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to interaction between substance use and psychiatric disorders, as well as recent head injuries.
In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to exposure to alcohol and drug use on his college campus. With regard to level of support of the recovery environment, the records support a score of 3. The patient was reluctant to seek support or help for his mental health issues and substance abuse while enrolled in college. In terms of treatment and recovery history, the records support a score of 1. There was no prior experience with treatment or recovery. With regard to engagement and recovery status, the records support a score of 3. The patients records documented limited ability to accept responsibility for recovery. Thus, the patient had a composite score of 20. In sum, medically monitored residence-based services were indicated in this setting. Therefore, wilderness treatment program services provided from 10/23/18 through 1/16/19 were medically necessary for the treatment of this patient.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 9b8160528952c76add7b36b9b395fe3c | ./data/processed/ca_cdi/summaries/20-7094.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 52-year-old male enrollee has requested authorization and coverage for olaparib (Lynparza) tablet 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that Lynparza has been approved for use in patients with BRCA positive breast cancer or ovarian cancer. There is early experience with Lynparza in prostate cancer, mostly demonstrating some efficacy only in patients with DNA repair mutations, such as BRCA or ATM (Sonnenburg and Morgans). This patient was found to have the FANCA mutation, which is a related type of mutation. However, thus far, there is a lack of data demonstrating that patients with this mutation will obtain a meaningful response to Lynparza. Clarke and colleagues suggested that regardless of mutation status, there is somewhat better progression free survival with a combination of Lynparza and abiraterone than with abiraterone alone, though there was considerable toxicity in the combination arm. Given these findings, the requested Lynparza tablet 100 mg is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 763fd0a7286c52cf03a64d96e6cb8396 | ./data/processed/ca_cdi/summaries/18-6372.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 52-year-old male enrollee has requested authorization and coverage for olaparib (Lynparza) tablet 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that the standard of care for prostate cancer includes use of docetaxel or cabazitaxel which have been demonstrated in phase III randomized trials to prolong survival. This patient did not progress on docetaxel and has not been treated with cabazitaxel. Further, additional agents referenced in the National Comprehensive Cancer Network (NCCN) guidelines have greater support for this patients condition than the proposed treatment. Mateo and colleagues reported that Lynparza may provide additional benefit in patients with a BRCA or ATM mutation. However, this patients records document the presence of a FANCA mutation, which has not been shown to increase the effectiveness of Lynparza. For these reasons, the requested Lynparza tablet 100 mg is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 763fd0a7286c52cf03a64d96e6cb8396 | ./data/processed/ca_cdi/summaries/18-6372.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 52-year-old male enrollee has requested authorization and coverage for olaparib (Lynparza) tablet 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that this patient has exhausted several prior lines of therapy. The PARP inhibitor Lynparza was studied in 49 patients with castration resistant prostate cancer (Mateo, et al). In this phase II study, all patients were previously treated with at least two prior regimens for castration resistant disease and all had received prior docetaxel chemotherapy. Among the patients with a DNA repair gene abnormality, 88% demonstrated a response. Given this support, the requested Lynparza tablet 100 mg is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication 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:: | 763fd0a7286c52cf03a64d96e6cb8396 | ./data/processed/ca_cdi/summaries/18-6372.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 29-year-old male enrollee has requested reimbursement for custom foot orthoses/inserts (L3030-NU, LT, RT) that were ordered on 1/10/15. The Health Insurer has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that this patient presented status post a trip and fall injury on 1/4/15 with acute low back, mid-back and right hip pain and disability. Clinical exam findings were consistent with the reported diagnoses of lumbar radiculitis, lumbar/lumbosacral subluxation, thoracic sprain/strain, and pelvic, hip, and pubic subluxation. There was no evidence of a foot condition/deformity or leg length discrepancy. There was no radiographic or imaging evidence of spinal segmental instability. The patient reported a 10-30% reduction in symptoms and functional improvement over the initial week of care. There is no compelling documentation presented to support the medical necessity of custom made bilateral foot orthoses for this patient. Therefore, in the absence of evidence based medical guideline or peer-reviewed support, the custom foot orthoses/inserts (L3030-NU, LT, RT) were not medically necessary for treatment of the patients medical condition. Based on the above, the equipment 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:: | 3d879859ffbf4d100465ef448cb895fd | ./data/processed/ca_cdi/summaries/16-4622.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The patient is a 40-year-old female with low back pain and right L5 and S1 radiculopathy. She is status post decompression and fusion at L5-S1 with pedicle screw fixation. The physician reviewer found that the requested laminectomy, facetectomy and foraminotomy are medically necessary for the treatment of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 6598b6bbba2b1a97757a2c9c9256bfcb | ./data/processed/ca_cdi/summaries/20-6993.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 15-year-old female diagnosed with major depressive disorder, recurrent, severe, alcohol use disorder, severe, and self-harm. The patient was admitted to intensive outpatient program (IOP) treatment on 1/19/17. The clinical record documents discord between the patient and her family. During the course of treatment, the patient has described herself as a mediator between her parents. An entry on 2/8/17 reveals that she was allowed to go on a trip with her father from 2/9/17 until 2/13/19, while in IOP. On 4/10/17, the patient reported less suicidal ideation but continued mood symptoms thus Prozac was increased from 20 mg daily for 30 mg daily with a plan to reassess in five weeks. Also on 4/10/17, she indicated in group that she does not express her anger in adaptive ways and she acknowledged that she wanted to learn more adaptive strategies. Her parent has requested reimbursement and prospective authorization and coverage for mental health IOP services from 4/10/17 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary. The additional information provided has been reviewed. On 5/24/17, an entry indicates that clients and parents attended a multifamily group. However, there is no indication the session focused on the specific issues and needs of this patient. Progress notes from other group encounters are similarly not specific to this patients needs and do not tailor care to the diagnoses and circumstances of the patient. Individual outpatient therapy and focused parent-child intervention in a less restrictive environment is likely to be more effective. More specific and focused treatment could be provided in a less restrictive setting. Accordingly, the IOP services provided from 4/10/17 forward were not and are not medically necessary for treatment of this patients behavioral health issues. Based on the foregoing discussion, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 4d523603de307b551e643eff580547ef | ./data/processed/ca_cdi/summaries/17-6013.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 62-year-old female enrollee has requested reimbursement for ChemoFX assay performed on 5/08/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found ChemoFx is an attempt to determine the likelihood of a specific chemotherapeutic agent being effective in a patient, by testing the growth of an individuals cancer in an environment of various agents in vitro. The hope is that drugs to which the cancer cells will respond to in vitro will then be clinically useful in that patient. Such personalized selection would then spare the patient the toxicity of drugs that would not be useful. There have been many such assays developed over the years. As yet, none has convincingly demonstrated that selecting the specific chemotherapeutic regimen under the guidance of this assay has given the patient a significantly better survival, when compared to selecting a regimen based on known clinical studies and standards. At this time, the evidence is insufficient to use the information from these assays to supplement standard of care chemotherapy decisions. All told, ChemoFx assay performed on 5/08/15 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 17a045b712dd54913e0dc72843fcfb1b | ./data/processed/ca_cdi/summaries/16-4337.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 62-year-old female enrollee has requested reimbursement for ChemoFX assay performed on 5/08/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found Chemosensitivity testing, such as ChemoFx, is not considered a standard of care and is not recommended by current guidelines. In vitro assays of chemosensitivity or resistance, such as the ChemoFx assay, have been developed as a method to select the optimal chemotherapy regimen or identify those agents least likely to be effective. However, the utility of these assays have not been prospectively validated. Therefore, ChemoFx assay performed on 5/08/15 was not likely to have been more efficacious than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 17a045b712dd54913e0dc72843fcfb1b | ./data/processed/ca_cdi/summaries/16-4337.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 62-year-old female enrollee has requested reimbursement for ChemoFX assay performed on 5/08/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found in vitro drug testing on patients tumor cells prior to applying chemotherapy is an appealing idea, but it is difficult to put into clinical use. The most thorough evaluation of these technologies was performed by the American Society of Clinical Oncology in 2004. In their review of this technology, the panel concluded that such in vitro drug testing should be limited to clinical trials. There is a lack of support for the services at issue in this clinical setting. Therefore, ChemoFx assay performed on 5/08/15 was not likely to have been more effective than other methods of evaluation. 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:: | 17a045b712dd54913e0dc72843fcfb1b | ./data/processed/ca_cdi/summaries/16-4337.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 1
A 25-year-old male enrollee has requested authorization and coverage for the LINX Reflux Management System. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The U.S. Food and Drug Administration (FDA) approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. This patient meets those specific criteria. A recent study comparing the LINX procedure with laparoscopic fundoplication was performed. This was a retrospective study 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 (Reynolds, et al). In addition, a five-year cohort data supports the durability of the device. 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 (Ganz, et al). Therefore, the request for the LINX Reflux Management System 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:: | 278d7e5512c6be696e8f25014fadc6b3 | ./data/processed/ca_cdi/summaries/17-6038.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 25-year-old male enrollee has requested authorization and coverage for the LINX Reflux Management System. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found in this case, the patient presents with non-acid dyspepsia as well as GERD, based on pH recording. The records demonstrate that the patient has benefited to a significant degree from acid suppression treatment to the same extent that his pH study showed correlation of acid reflux events and heartburn. Thus, the patient cannot be considered medically refractory to acid blocker drugs, and does not meet the U.S. Food and Drug Administration (FDA) indication for implantation of the LINX device. In addition, the, implantation of LINX in this clinical setting must be approached with caution given the patients documented complaint of dysphagia. For the reasons provided, the request for the LINX Reflux Management System 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:: | 278d7e5512c6be696e8f25014fadc6b3 | ./data/processed/ca_cdi/summaries/17-6038.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 25-year-old male enrollee has requested authorization and coverage for the LINX Reflux Management System. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment (Sheu, et al; Ganz). For these reasons, LINX Reflux Management System 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:: | 278d7e5512c6be696e8f25014fadc6b3 | ./data/processed/ca_cdi/summaries/17-6038.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 47-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 medical condition. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials. All told, the requested medication Harvoni is medically indicated for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| [
"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:: | 817098986e0e52a46fb90e592682fc46 | ./data/processed/ca_cdi/summaries/15-4290.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers especially in patients with extremely and heterogeneously dense tissue. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done using two-dimensional imaging alone. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 8b721ac40184b89fd149c77ac4cb2f02 | ./data/processed/ca_cdi/summaries/16-4556.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case. According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. In sum, digital breast tomosynthesis performed on 1/21/16 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:: | 8b721ac40184b89fd149c77ac4cb2f02 | ./data/processed/ca_cdi/summaries/16-4556.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this patients case, her breasts were described as heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast tomosynthesis performed on 1/21/16 was likely to have been superior over other modalities for 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:: | 8b721ac40184b89fd149c77ac4cb2f02 | ./data/processed/ca_cdi/summaries/16-4556.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/27/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the standard protocol for an intermediate thickness tumor such as in this case does not include a work-up with molecular genetic testing. Although DecisionDx-Melanoma testing has shown results in predicting risk of metastasis, there is no set change in treatment protocol based on the findings. Currently the standard of care includes wide local excision and a sentinel node biopsy and the decision to pursue medical treatment would be based on the results of these tests. There are no clinical studies at this time that show that the results of the molecular testing will make a difference in the treatment or morbidity or mortality of the patient. For the reasons provided, the DecisionDx-Melanoma testing performed on 10/27/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 52caac4fb1e043bea24c8a0e0ae06d37 | ./data/processed/ca_cdi/summaries/18-6251.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/27/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Although DecisionDx Melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. For this reason, the DecisionDx-Melanoma testing performed on 10/27/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 52caac4fb1e043bea24c8a0e0ae06d37 | ./data/processed/ca_cdi/summaries/18-6251.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/27/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma assay should not be used outside of a clinical trial setting. The use of DecisionDx-Melanoma testing is not the standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the patients treatment or health outcome. All told, the DecisionDx-Melanoma testing performed on 10/27/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 52caac4fb1e043bea24c8a0e0ae06d37 | ./data/processed/ca_cdi/summaries/18-6251.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
An 18-year-old female enrollee has requested reimbursement for psychiatric residential treatment from 11/24/14 through 1/08/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient was not a danger to herself or others. She participated in her treatment plan. She tolerated her medications without adverse events. She was learning to contain herself and deal with her emotions. Her living environment was supportive, and there was no evidence that returning her to the community would have led to a decompensation in her condition. She had no coexisting medical conditions. She did not require 24 hour nursing and medical supervision and although she required ongoing psychological and psychiatric treatment, this could have occurred at a lower level of care. All told, psychiatric residential treatment from 11/24/14 through 1/08/16 was not medically indicated for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| [
"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:: | cc82617d97c7a7589c50ec757e966d8a | ./data/processed/ca_cdi/summaries/16-4425.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 47-year-old male enrollee has requested authorization and coverage for Dupixent (dupilumab). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees atopic dermatitis. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has a chronic history of moderate to severe atopic dermatitis which has been unresponsive to treatment with numerous medium to ultrapotent topical steroids, topical immunomodulators and intramuscular steroids. Dupixent is a U.S. Food and Drug Administration (FDA) approved injectable biologic for the treatment of moderate to severe atopic dermatitis. Given that the patient has had a lifelong history of moderate to severe atopic dermatitis and has failed management with topical and systemic steroids as well as topical immune modulators, Dupixent is medically appropriate. The long-term risks of continued use of topical or systemic steroids has been well-established. Thus, Dupixent (dupilumab) 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:: | 70c2f169c900ab98c93acf181290a78e | ./data/processed/ca_cdi/summaries/18-6493.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 55-year-old female with duplex documented right great saphenous vein reflux and a vein measuring greater than 6 mm at the saphenofemoral junction and further down the thigh. She has completed conservative measures and has had previous interventions. The patient has requested authorization and coverage for varicose vein surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. There is sufficient support for the requested services in this clinical setting. Despite prior interventions, this patient remains symptomatic. Additionally, the records document a prior course of conservative treatment. Per the records, her prior treatment included compression hose, elevation, exercise and Motrin. The medical evidence supports the requested services in this patients case. Thus, the requested varicose vein surgery is medically necessary for the treatment of this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
| [
"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:: | bb62db2329bfd3823ed70b709ee7ea09 | ./data/processed/ca_cdi/summaries/18-6335.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 52-year-old female with a reported history of chronic back pain dating back to 2005.The patient has requested authorization and coverage for cervical spine MRI and thoracic spine MRI. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. The physician reviewer found that there are two studies currently under question. The first is an MRI of the cervical spine. In the medical records, there is no mention of any signs or symptoms pointing to the neck. In view of this, there is no indication for any imaging of the cervical spine. For the thoracic spine MRI, the records noted that the patient had a T3-4 radiculopathy. Conceivably, she could have a compression fracture or focal arthritic change. Remotely, she could even have a significant lesion, such as a severe fracture or even a mass. While the likelihood of these possibilities is low, an MRI is the best means to pick up a focal abnormality. The presence of radiculopathy is also considered a legitimate indication for an MRI. In conclusion, there is no indication for a cervical spine MRI. However, the thoracic spine MRI could help in management, Therefore, the requested thoracic spine MRI is medically necessary for the evaluation of this patient.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | ea9ece02412fd83a5873ebf1faec8276 | ./data/processed/ca_cdi/summaries/20-7079.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 40-year-old male enrollee has requested reimbursement for emergency room services provided on 1/24/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found the patient is a 40-year-old male who presented to the emergency department on 1/24/17 with reports of back pain. He reported low back pain that had commenced two weeks prior. Carrying his daughter on his shoulders had worsened his discomfort. Ibuprofen, rest, and ice had not alleviated his pain. He denied any fever, numbness, tingling, or loss of bowel or bladder control. The patients vital signs included blood pressure of 131/92, respiratory rate of 18, and a temperature of 98.8 F. Mild discomfort in the lumbosacral region was noted without radiation or step-offs. He had a positive straight leg raising and antalgic gait. No obvious sensory or motor deficits were present. The record notes that the patient had good strength of his hip, knee, and ankle dorsi- and plantar flexion. Normal reflexes were present. An x-ray revealed mild degenerative changes with endplate spur formation at L3-4 and mild facet arthropathy at L4-5 and L5-S1. He was treated with intramuscular Toradol and Flexeril. The patient was assessed with back pain and discharged home with improved symptoms. The patient has requested reimbursement for emergency services provided on 1/24/17. At issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with back pain that had commenced two weeks prior. He had not suffered any trauma. He denied any neurologic symptoms. The patient was afebrile with normal vital signs. He had normal motor strength and no sensory deficits. Given that the patients symptoms were not acute in onset or severe, and he had not suffered any trauma, his symptoms do not meet prudent layperson criteria for an emergency medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided on 1/24/17 did not meet prudent layperson criteria for emergency care. | [
"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:: | e093cdab4ff66039fad3460c97b15075 | ./data/processed/ca_cdi/summaries/17-6062.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 53-year-old female enrollee has requested has requested authorization and coverage for Sovaldi and Daklinza. 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 according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of the fibrosis stage. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection. Therefore, 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:: | ad9d5035026b4559ff74382a7e48539c | ./data/processed/ca_cdi/summaries/16-4764.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 54-year-old male enrollee has requested reimbursement for inpatient admission on 6/3/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees lower abdominal pain. The physician reviewer found that impatient care is medically necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. Outpatient observation admission is appropriate when the provider is unsure about the patients need for inpatient admission and requires time for short-term treatment, assessment, and reassessment in order to make that decision or the physician anticipates that the patients condition can be evaluated and treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this case, the patient was admitted in stable condition and could have been treated at an observational level of care. He was tolerating oral fluids and his pain was well controlled. The patient remained hemodynamically stable without a need for any urgent procedures. Thus, the patient could have been treated at a lower level of care. As such, the inpatient admission on 6/3/16 was 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:: | a5a99fe9f439aa2a5ad86a6eee3674ef | ./data/processed/ca_cdi/summaries/17-6075.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 34-year-old male enrollee has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. the physician reviewer found THE requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard. The patient does not have clinically documented late stage Lyme disease either in the form of Lyme arthritis or neuroborreliosis. Tremor alone is not a finding in late stage Lyme disease. In addition, the patient does not have laboratory results documenting late stage Lyme. There is no IgG positive titer or positive cerebrospinal fluid or synovial fluid results. There is no joint effusion and no neurologic deficits documented. Moreover, the treatment of late stage Lyme disease, if established, is a four-week course of intravenous ceftriaxone. Long courses or repeat courses of antibiotic have not demonstrated efficacy in multiple trials. In sum, there is a lack of documentation supporting a diagnosis of late stage Lyme disease. Therefore, the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 7cc04f4e93c7ff0787eda2de12fcc6cb | ./data/processed/ca_cdi/summaries/16-4387.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 34-year-old male enrollee has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found the patient is a 34-year-old male who has been diagnosed with persistent Lyme disease. He had a positive IgM Western blot for Lyme with a negative IgG western blot for Lyme on 3/28/13. There is no further laboratory testing submitted to support a diagnosis of secondary, tertiary or chronic Lyme or neuroborreliosis. An office visit note dated 9/9/15 indicates that the patient reports doing better in general and marked improvement with starting Bicillin. The patient reports improved strength, less tremor/shaking and improvement in cognitive function. The assessments are listed as Lyme disease, anxiety state, attention or concentration deficit, malaise, fatigue, myalgia and myositis, headache, bartonellosis, candidiasis of mouth and disturbance of skin sensation. In the patients appeal letter, he states that has been using Bicillin L-A since July 2015 and has improved shaking and vibrating, more energy, less tingling, trouble walking, memory and nerve problems and more. The patient has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request as investigational.
Based on the documentation submitted for review, there is a lack of evidence demonstrating the patient has chronic Lyme disease. The laboratory data shows that he may have had acute or early Lyme in September 2013, but no evidence of ongoing infection is submitted. In the absence of evidence of ongoing infection with Borrelia or any other tick born disease, antibiotic treatment is less likely to be of benefit. In addition, the Infectious Diseases Society of America (IDSA) guidelines report that long term antibiotic treatment does not improve the outcome in patients suffering from Lyme, post Lyme or chronic Lyme. Thus, continued use of antibiotics beyond a month without evidence of ongoing infection cannot be justified. Given the above, Bicillin L-A is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 7cc04f4e93c7ff0787eda2de12fcc6cb | ./data/processed/ca_cdi/summaries/16-4387.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 34-year-old male enrollee has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found Bicillin is a long acting form of penicillin G which generates protracted low levels of penicillin in the blood and has been used primarily for the treatment and prevention of streptococcal infections. It has also been used in the therapy of syphilis and related spirochetal infections. However, there is a lack of published medical literature that supports the use of this drug in the treatment of Lyme disease. Moreover, it is not a recommended therapy per the Infectious Diseases Society of America guidelines (Wormser, et al). Therefore, the use of Bicillin L-A is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 7cc04f4e93c7ff0787eda2de12fcc6cb | ./data/processed/ca_cdi/summaries/16-4387.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 1
A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 8/30/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients who had had sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not known if the DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing provided on 8/30/19 was not 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:: | d90e2601114ae92a32c057ac47adebfa | ./data/processed/ca_cdi/summaries/20-7148.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 8/30/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. The physician reviewer found that this patient has an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Newer prognostic molecular techniques should not replace standard staging procedures. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Thus, DecisionDx-Melanoma testing provided on 8/30/19 was not 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:: | d90e2601114ae92a32c057ac47adebfa | ./data/processed/ca_cdi/summaries/20-7148.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 8/30/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision but they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. All told, DecisionDx-Melanoma testing provided on 8/30/19 was not 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:: | d90e2601114ae92a32c057ac47adebfa | ./data/processed/ca_cdi/summaries/20-7148.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
The patient is a 40-year-old female with a history of breast cancer. On 7/01/19, she underwent a bilateral mastectomy with bilateral deep inferior epigastric perforator (DIEP) flap reconstruction. The physician reviewer found that the DIEP flap was for breast reconstruction and was medically necessary. However, the service in dispute in this case is code 15734. Code 15734 describes muscle, myocutaneous, or fasciocutaneous flap, trunk. This code is used in the setting of ventral hernia repair or for repair of wide diastasis recti. The medical records do not support this code in this patientas case. Based on the submitted medical records, there was no ventral hernia repair or repair of wide diastasis recti reported. Per the submitted records, no abdominal weakness or hernia was reported as being present to require a separation of parts repair. Therefore, 15734-59-62 and 15734-62 performed on 7/01/19 were not medically necessary for the treatment of this patient.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | a1b3a3b70a256299364498e2ce359e71 | ./data/processed/ca_cdi/summaries/20-7206.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 28-year-old female enrollee has requested reimbursement for computer-aided detection performed on 4/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has BRCA2 gene mutation. The physician reviewer found that there is sufficient support for the services at issue in this patients case. In young females, breast tissue is almost always mammographically dense, which limits the utility of mammography. MRI is the procedure of choice for annual screening in these patients due to the high sensitivity of the test for breast cancer. Mammography also is of use beginning at age 30, and annual examination with both modalities is recommended at that age. Per the medical evidence, computer-aided detection performed on 4/20/18 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:: | 18cfe03479673956619c5dd8dd030a78 | ./data/processed/ca_cdi/summaries/19-6591.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 28-year-old female enrollee has requested reimbursement for computer-aided detection performed on 4/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has BRCA2 gene mutation. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The Health Insurer is covering the breast MRI with contrast performed on 4/20/18, consistent with accepted medical practice for female patients with the BRCA2 mutation. There is a lack of peer-reviewed literature supporting better outcomes when computer-aided detection is added to breast MRI in screening for patients with increased risk of breast cancer. Thus, computer-aided detection performed on 4/20/18 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:: | 18cfe03479673956619c5dd8dd030a78 | ./data/processed/ca_cdi/summaries/19-6591.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 28-year-old female enrollee has requested reimbursement for computer-aided detection performed on 4/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has BRCA2 gene mutation. The physician reviewer found that contrast-enhanced breast MRI is approximately 90% sensitive for the detection of breast cancer in the high risk population, whereas ultrasound and mammography are approximately 38% sensitive individually in this population. Computer-aided detection is software that is used as part of the interpretation of the MRI, which helps to analyze the breast tissue and possible abnormalities. It is considered an integral part of the breast MRI examination. Screening contrast-enhanced breast MRI beginning at age 25 is recommended in women with BRCA gene mutations, their untested first degree relatives, and women with a lifetime risk of greater than 20%. MRI with mammography is recommended starting at age 30. This patient has a known BRCA2 gene mutation, which is considered one of the highest risk populations for breast cancer. In this setting, the medical evidence supports annual screening MRI examinations including computer-aided detection. Thus, computer-aided detection performed on 4/20/18 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:: | 18cfe03479673956619c5dd8dd030a78 | ./data/processed/ca_cdi/summaries/19-6591.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
The patient is a 17-year-old female with migraine headaches, postural orthostatic tachycardia syndrome, and significantly elevated lactate. Her headaches have been treated with several medications, with some reduction in pain, but she continues to miss school for the associated symptoms of nausea and dizziness. Her provider suspected a mitochondrial disorder and ordered mitochondrial DNA sequencing. The Health Insurer has denied reimbursement for genetic testing (mitochondrial genome sequencing) performed on 12/31/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient. There is sufficient support for the services at issue in this clinical setting. Mitochondrial disorders are challenging to diagnose because they can present at any age, have a wide spectrum of clinical symptoms, and are often insidious in onset. Because energy production is a need of all tissues, mitochondrial disease can present with virtually any symptom. While there are some well-described mitochondrial syndromes, many patients with mitochondrial disease do not fall neatly into one of the described syndromes. The advent of mitochondrial genome sequencing and whole exome sequencing have obviated the need for invasive testing, such as muscle biopsy. Patients with mitochondrial disease need comprehensive multidisciplinary care, optimally through a mitochondrial specialty center. There are consensus-based guidelines for treatment and surveillance of these multisystem disorders. In order to determine whether these recommendations should be applied to the patient, a diagnostic evaluation is needed to determine whether a mitochondrial disorder is responsible for the patients symptoms. Mitochondrial genome sequencing is an integral part of such a diagnostic evaluation, and is standard of care for the evaluation of mitochondrial disorders. Therefore, genetic testing (mitochondrial genome sequencing) performed on 12/31/16 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:: | 1005f55f2bbc9a984cc64793823a55c2 | ./data/processed/ca_cdi/summaries/18-6253.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
The patient is a 17-year-old female with a medical history significant for daily migraine headaches refractory to standard outpatient management, periods of nausea and dizziness, and a diagnosis of postural orthostatic tachycardia syndrome (POTS). The records documented concern for an underlying mitochondrial disorder as the unifying diagnosis for her complex symptomatology. Thus, mitochondrial genome sequencing was ordered and performed. The Health Insurer has denied reimbursement for genetic testing (mitochondrial genome sequencing) performed on 12/31/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient. Mitochondria are responsible for cellular energy production in nucleated cells. Dysfunction may occur as a result of defects in either mitochondrial DNA or nuclear mitochondrial genes, and resulting disease may present in either adulthood or childhood. Symptoms may affect one organ or may involve multiple systems. While there is no cure for mitochondrial disease at present, genetic diagnosis is essential for guiding supportive care, as well as providing counselling to families and the patient. Next generation sequencing techniques have been invaluable in diagnosing patients with clinical findings suggestive of mitochondrial disease. In this patients case, she has numerous clinical and biochemical abnormalities that have raised the question of mitochondrial disorder. The information provided by next generation sequencing was important for guiding her future care. In sum, genetic testing (mitochondrial genome sequencing) performed on 12/31/16 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:: | 1005f55f2bbc9a984cc64793823a55c2 | ./data/processed/ca_cdi/summaries/18-6253.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
The patient is a 17-year-old female with a history of migraines and postural orthostatic tachycardia syndrome. The provider noted that the patient has a constellation of multisystem involvement consistent with a diffuse metabolic disorder with abnormal lactate and pyruvate levels. The records document that a mitochondrial disorder was considered. The provider noted that that establishing a diagnosis was important because management would be altered. The Health Insurer has denied reimbursement for genetic testing (mitochondrial genome sequencing) performed on 12/31/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient. Molecular genetic diagnostic testing for mitochondrial disease has evolved continually since the first genetic basis for a clinical mitochondrial disease syndrome was identified in the late 1980s. Diagnosis via genetic testing for mitochondrial disease involves newer technologies and are the new gold standard methodology for mitochondrial DNA genome sequencing. In the absence of clear-cut genotype-phenotype correlations, biochemical analyses are the cornerstone of the diagnosis of this condition. In this case, the clinical picture was consistent with a mitochondrial DNA disorder. Thus, the services at issue were appropriate in this setting. In sum, genetic testing (mitochondrial genome sequencing) performed on 12/31/16 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:: | 1005f55f2bbc9a984cc64793823a55c2 | ./data/processed/ca_cdi/summaries/18-6253.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
An 18-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 6/23/17 through 7/16/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that submitted documentation supports the medical necessity of the services at issue. The patient has an extensive psychiatric history involving multiple prior inpatient treatment programs. The patient had a serious suicide attempt on 5/26/17 with Ativan and Vodka, which can be a lethal combination. The patient has a history of self-harm and is impulsive. She was ambivalent about treatment goals. It appears that the patient decompensated in less restrictive settings. There is sufficient support for the services at issue in this clinical setting. The records indicate that the patient had failed less restrictive means for treatment. Thus, mental health residential treatment provided from 6/23/17 through 7/16/17 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. | [
"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:: | c7c1dae53bbc2b0361dd1964b597e28a | ./data/processed/ca_cdi/summaries/18-6381.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 57-year-old male who presented to the emergency department of Mercy Medical Center in Redding, California with complaints of nausea, vomiting, decreased oral intake and epigastric abdominal pain radiating to the back. The patient has requested reimbursement for air ambulance transport provided on 10/16/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that in order for air medical transport to be medically necessary, all medical necessity criteria must be met. These criteria include: the patientas condition must be such that any form of transportation other than ambulance would be medically contraindicated; the individualas condition is such that time needed to transport by ground poses a threat to the patientas survival; the individual is transported to the nearest hospital with appropriate facilities for treatment; and there is a medical condition that is life-threatening. When transporting from one facility to another, the above criteria must be met, and the first hospital does not have the required services and facilities to treat the patient. Per the submitted documentation, this patient required an ERCP. Mercy Medical Center did not have gastroenterology services available to perform an ERCP. The documentation noted that California Pacific Medical Center a Van Ness was the closest facility with available gastrointestinal services. Time for ground transportation was at minimum 3 hours and 37 minute via a toll road. Generally, ground transport times greater than 30 minutes would justify the initiation of air transport. Transport by air took 1 hour and 28 minutes. There is sufficient support for air ambulance transport in this case. Therefore, air ambulance transport provided on 10/16/20 was 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:: | 6cc24e3cbd868400bde6ff79ae48eae5 | ./data/processed/ca_cdi/summaries/21-7379.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 29-year-old female with Crohnas disease. The patient has requested authorization and coverage for Stelara (ustekinumab IV solution 130 mg/26 ml (5 mg/ml). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that this patient has moderate to severe Crohnas disease based on age below 30 at diagnosis. Per American Gastroenterological Association guidelines for therapy of moderate to severe Crohnas disease, immunosuppressants, such as azathioprine, 6-mercaptopurine, and methotrexate, are not recommended as primary monotherapy. For patients with moderate-severe Crohnas disease, immunosuppressants may take up to 17 weeks to be effective, and aminosalicylates, corticosteroids, and antibiotics are not recommended as long-term primary therapy as they are unlikely to prevent complications. American College of Gastroenterology guidelines also do not recommend immunosuppressants or methotrexate as primary monotherapy for the induction of remission of Crohnas disease, stating, aAzathioprine and 6-mercaptopurine are not more effective than placebo to induce short-term symptomatic remission and should not be used in this manner.a The guidelines do recommend Stelara as a primary monotherapy for the treatment of Crohnas disease. A large randomized controlled trial by Sandborn and colleagues demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohnas disease. Another study by Kopylov and colleagues showed a 73% response in patients with anti-tumor necrosis factor-resistant Crohnas disease, and 80% of responders maintained remission for one year. A significant majority of these patients were able to discontinue steroids. Therefore, Stelara (ustekinumab IV solution 130 mg/26 ml (5 mg/ml) is medically necessary for the treatment of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e4a8761229e3f3ae547b92afb59a6aa7 | ./data/processed/ca_cdi/summaries/21-7253.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 64-year-old female enrollee has requested reimbursement for gene testing performed on 10/30/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells, with the hope that it will identify a specific mutation or target that could guide the clinician as to which chemotherapeutic agent would be useful. 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. A randomized study by Le Tourneau and colleagues did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Finding a mutation does not guarantee that a drug targeting that mutation will be beneficial. Multiple editorials have questioned the overall approach to treatment using such molecular panels. Therefore, gene testing performed on 10/30/17 was not likely to have been more effective than other available method for 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:: | 75ea199b042b497a4a16e2b15da5197f | ./data/processed/ca_cdi/summaries/19-6731.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 64-year-old female enrollee has requested reimbursement for gene testing performed on 10/30/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing to predict candidates for specific mutation-driven treatment holds promise but is not yet ready for routine clinical use. Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of next generation sequencing, such as with FoundationOne testing, continues to be the subject of ongoing clinical trials. In sum, gene testing performed on 10/30/17 was not likely to have been superior over other methods of evaluating this patient.
| [
"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:: | 75ea199b042b497a4a16e2b15da5197f | ./data/processed/ca_cdi/summaries/19-6731.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 64-year-old female enrollee has requested reimbursement for gene testing performed on 10/30/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that next-generation sequencing, such as provided by FoundationOne is an appropriate medical diagnostic test for this difficult situation. It is medically appropriate to offer this patient the opportunity to participate in clinical trials. FoundationOne genetic testing is an accepted standard and appropriate diagnostic approach for the identification of clinical trials that would be suitable for this patient, based on tumor mutational analysis. At the time of testing in October 2017, metastatic breast cancer patients had targeted therapy options available through standard of care. Patients with BRCA mutations identified by genomic testing could pursue therapy with olaparib, which was demonstrated to be superior to standard chemotherapy. Additionally, patients with metastatic breast cancer can have tumor mutations for microsatellite instability and DNA mismatch repair, making them eligible for standard treatment with pembrolizumab. The use of FoundationOne testing is an appropriate diagnostic assay for the determination of eligibility for these approved therapies. Use of pathology tests with next-generation sequencing, including FoundationOne genetic testing, was likely to have be more beneficial for this patients medical condition than the choice of available standard therapies based on empirical therapeutic choice processes, as this has the possibility to identify therapies that may be more effective with less toxicity, or to identify potential candidacy for targeted clinical trials that may be provide greater benefit than empiric choice of chemotherapies. Thus, gene testing performed on 10/30/17 was likely to have been of greater benefit 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:: | 75ea199b042b497a4a16e2b15da5197f | ./data/processed/ca_cdi/summaries/19-6731.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 1
A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the U.S. Food and Drug Administration has approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm. This patient meets those specific criteria. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter closure pressure, but allow for food passage with swallowing. Based upon a prospective study by Lipham and colleagues that included 44 patients, the mean total percent time that pH was less than 4 was reduced from 11.9 percent at baseline to 3.8 percent at three years. A recent study comparing the LINX procedure with laparoscopic fundoplication was performed by Reynolds and colleagues. The authors found that gastroesophageal reflux disease 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. Therefore, the LINX Reflux Management System (code 43284) and one inpatient day are likely to be superior over 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:: | 536245dfe30e2f0e90c2cceff00dc98e | ./data/processed/ca_cdi/summaries/19-6753.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that appropriate patient selection is crucial before anti-reflux procedures. On 1/09/19, the patients provider noted the off-drug pH study comes back with normal DeMeester scores, and cannot substantiate the diagnosis of significant reflux. Per the records, upper endoscopy did not document significant reflux esophagitis either. Further, the patient cannot be considered medically refractory to maximally dosed acid suppression. Additionally, the records document significant esophageal dysmotility. The risks, medical appropriateness, or necessity of LINX in the setting of hypertonic esophageal motility disorder is not apparent. In this case, the requested services are not likely to be more beneficial for treatment of the patients medical condition than available standard therapy, such as weight loss, lifestyle modification, further characterization of lower esophageal reflux dysfunction, and maximal proton pump inhibitor use. In sum, the LINX Reflux Management System (code 43284) and one inpatient day are not likely to be of greater benefit than other treatment options.
| [
"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:: | 536245dfe30e2f0e90c2cceff00dc98e | ./data/processed/ca_cdi/summaries/19-6753.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Skubleny and colleagues concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia, requiring endoscopic intervention, which is a concern in this patient with hypertensive lower esophageal sphincter. 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, surgical fundoplication. Thus, the LINX Reflux Management System (code 43284) and one inpatient day are not likely to be more effective 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:: | 536245dfe30e2f0e90c2cceff00dc98e | ./data/processed/ca_cdi/summaries/19-6753.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 49-year-old female enrollee has requested authorization and coverage for endoluminal ablation. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees varicose veins. The physician reviewer found that the documentation supports the medical necessity of the requested endoluminal ablation. The patient is experiencing significant worsening edema in the right leg that limits her ability to perform activities of daily living despite conservative treatments including the use of medical grade compression stockings. In addition, the Duplex findings are remarkable with respect to the large size of the involved vein and the extensiveness of the reflux. Given these findings, the treatment plan is both appropriate and medically necessary. 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:: | 12119ce1b704a742db9d8cc4a7c32239 | ./data/processed/ca_cdi/summaries/16-4772.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 33-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg tablets 60/30 days. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollee/s medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has failed alternatives, including multiple anti-tumor necrosis factor (TNF) medications. Xeljanz has a different mechanism of action than anti-TNF therapies and Entyvio. Xeljanz is U.S. Food and Drug Administration (FDA) approved (at up to 10 mg twice daily, with lower dosage for several factors) for the treatment of ulcerative colitis, and has proven to be effective in a double-blind, placebo-controlled trial of patients with moderate-severe ulcerative colitis. In this patient with severe disease and failure of multiple biologic medications of different classes, Xeljanz is medically indicated. Therefore, Xeljanz 5 mg tablets, 60 per 30 days are medically necessary for the treatment of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | b44c63f4d14fc62d7f3dcdb010ba49c2 | ./data/processed/ca_cdi/summaries/19-6676.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 70-year-old male enrollee has requested reimbursement for an attended sleep study performed on 1/9/17. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary for evaluation of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that there has been a shift in the provision of care from the attended setting to the ambulatory/home environment for sleep studies. This has been accomplished through the technological advancements associated with auto-titrating continuous positive airway pressure devices (APAP and AutoPAP). These devices are used to maintain a patent oropharynx in the treatment of patients with OSA. APAP devices titrate effective airway pressure throughout the night using an algorithm that responds to physiologic signals, allowing for use outside of a sleep center. Current medical literature including randomized studies has shown that the use of an AutoPAP produces an equivalent outcome to attended CPAP titrations (Rosen, et al; Berry and Sriram; Chai-Coetzer, et al). In this case, there was no documentation provided for review that AutoPAP was trialed. He was then referred for an attended CPAP titration. Nor did the patient have any comorbid medical conditions that would be expected or to degrade the quality of an AutoPAP in the home setting. The provision of services in the laboratory setting would be considered to exceed the clinical needs and services required for the effective management of the patients condition. Such services could have been provided in a less resource intense setting as well. For these reasons, the attended sleep study performed on 1/9/17 was not medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the diagnostic procedure at issue was 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:: | 90fca40478d2b0b46339e7a4a2a314c1 | ./data/processed/ca_cdi/summaries/18-6285.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 19-year-old male enrollee has requested reimbursement for 84999 performed on 10/17/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines 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 trial. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, 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, CPT 84999 performed on 10/17/18 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:: | e20dfe7c8b521ccb59b3cca7df38f263 | ./data/processed/ca_cdi/summaries/19-6782.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 33-year-old female enrollee has requested reimbursement for the residential mental health treatment services provided from 3/2/17 through 3/16/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that the modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings optimize treatment gains while episodic placement in more restrictive settings can be clinically appropriate for patients with significant mental illness. The American Psychiatric Association (APA) states that the provider should determine the least restrictive setting for treatment that will be most likely not only to address the patients safety, but also to promote improvement in the patients condition. In this particular case, the patient presented with co-occurring bipolarity and anxiety. Patients with bipolar disorder spend a disproportionate time in the depressed phase. This is of particular relevance since it has been well-established in both clinical practice and the medical literature, such as the definitive Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, that anxiety-ridden mood disorders are difficult to treat and in general have poorer outcomes. Further, the patient had previously failed treatment in a less restrictive setting. Thus, the residential admission was indicated. During the disputed timeframe, the patient consolidated treatment gains and remained engaged in active treatment. However, discharge on 3/2/17 would have been premature and more than likely would have resulted in undue morbidity and re-admission. The services and setting were safe, appropriate and consistent with good practice, while the duration of the admission aligned with community standards. Additionally, the services provided were reasonably expected to improve her condition and prevent a more serious episode of illness. Considering the clinical presentation and perusal of the peer-reviewed literature, the residential mental health treatment services provided from 3/2/17 through 3/16/17 were medically necessary for treatment of the patients behavioral health condition. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. | [
"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:: | 37ee59a251a5c6816f64b3b634a20f59 | ./data/processed/ca_cdi/summaries/18-6184.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 64-year-old female enrollee has requested reimbursement for knee injections provided on 6/15/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees knee pain. The physician reviewer found that this patient presented on 6/15/18 with recurrent right knee pain and limitations in functional mobility and activities of daily living. Clinical examination findings were consistent with reported radiographic evidence of right knee degenerative joint disease. Reasonable conservative treatment, including medications, activity modification, weight loss, and physical therapy have failed to provide adequate symptom relief. She was status post previous injections on 12/19/16 and 9/22/17 which had provided sustained pain relief and functional improvement for longer than six months. Evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Thus, knee injections provided on 6/15/18 were 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:: | fe5f5574845b0d353978ab1679ed1a1b | ./data/processed/ca_cdi/summaries/19-6593.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 20-year-old male enrollee has requested reimbursement for residential treatment, partial hospitalization program services and intensive outpatient program services provided from 3/6/15 through 5/3/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the services at issue were not medically indicated for this patient during the dates in dispute. According to the documentation submitted for review, the patient presented to residential treatment on 3/6/15 with mild. He was not a danger to himself or others. There were no emotional, behavioral, or cognitive barriers requiring residential treatment. He was psychiatrically stable. Although his liver function tests were elevated, he was medically stable. He participated in the program and was motivated. He did not require 24-hour monitoring at residential level of care. As of 3/25/15, partial hospitalization program services were not clinically indicated. The patient no longer had PAWS and he was not at risk to himself or others. He was counseled regarding the need to monitor his liver function tests and liver health. His overall mood was euthymic. As of 3/25/15 he could have been stepped down to a lower level of care. Further, the intensive outpatient program services were not indicated for this patient. As of 4/17/15, he had a sponsor, and he was actively attending meetings/groups, and was employed. He was highly motivated. His mother was participating in family sessions. There were no emotional, behavioral, or cognitive barriers to treatment at a lower level of care. Therefore, the residential treatment, partial hospitalization program services and intensive outpatient program services provided from 3/6/15 through 5/3/15 were not medically necessary. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
| [
"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:: | fb04913e15fed614472bc0b51b2979f9 | ./data/processed/ca_cdi/summaries/16-4586.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
The parent of a 16-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) testing performed on 4/26/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for the enrollees dysmorphic facies and postural and kinetic tremor. The physician reviewer found the array-based CGH, also known as CMA, has become standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or multiple congenital anomalies. Until recently, it was a diagnostic test that was employed when the first-line investigation of karyotype returned normal. Subsequently, CGH has emerged as a first-line investigation. The yield of this test is estimated to be 8-17% and varies with the degree of cognitive impairment, the presence of dysmorphic features, and the presence of congenital anomalies. More recently, data have shown that actionable findings from chromosomal microarray justify its use (Coulter, et al). Based on the support in the peer-reviewed literature, the CGH testing performed on 4/26/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 230f6cee75838fc02675b048a0f942fc | ./data/processed/ca_cdi/summaries/17-4905.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
The parent of a 16-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) testing performed on 4/26/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for the enrollees dysmorphic facies and postural and kinetic tremor. The physician reviewer found that CGH, also referred to as CMA, is a well-established first-line genetic test for individuals with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics (AAP), the American College of Medical Genetics (ACMG), the American College of Neurology (AAN) and the Child Neurology Society (CNS) (Schaefer et al; Moeschler et al; Shevell, et al; Shen et al). CMA technology has been shown to provide clinically actionable information. In this case, the patient presented with kinetic tremor. The clinical utility of CMA in the evaluation of seizure concerns is also well established. Olson and colleagues evaluated 805 patients with epilepsy/seizures using CMA technology. The authors found that in at least 40 cases (5%), the epilepsy phenotype was explained by a [copy number variant] CNV, including 29 patients with epilepsy-associated syndromes and 11 with likely disease-associated CNVs involving epilepsy genes or hotspots. Copy number abnormalities were found to play an important role in patients with epilepsy. The authors concluded that because the diagnostic yield of CMA for epilepsy patients is similar to the yield in autism spectrum disorders and in prenatal diagnosis, for which published guidelines recommend testing with CMA, we recommend the implementation of CMA in the evaluation of unexplained epilepsy. For these reasons, CGH testing performed on 4/26/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"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:: | 230f6cee75838fc02675b048a0f942fc | ./data/processed/ca_cdi/summaries/17-4905.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
The parent of a 16-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) testing performed on 4/26/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for the enrollees dysmorphic facies and postural and kinetic tremor. The physician reviewer found thatCGH, also known as chromosomal microarray (CMA), is recommended by the American College of Medical Genetics (ACMG) as a first-tier test for patients with autism spectrum disorders or developmental delay and intellectual disability. The yield of CMA in patients with these disorders is estimated to be around 10%. However, there is no indication that this patient has these conditions. The clinic notes report that he has anxiety and depression with hallucinations, tremor, and differences in sensation. The notes also mention mild dysmorphic features, however these were not specified. In this clinical setting, the yield of CMA is likely to be low for this patient. As such, the CGH testing performed on 4/26/16, was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"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:: | 230f6cee75838fc02675b048a0f942fc | ./data/processed/ca_cdi/summaries/17-4905.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 91-year-old male enrollee has requested reimbursement for services provided from 3/13/18 through 3/16/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees acute on chronic diastolic heart failure. The physician reviewer found that the records provided for review document that this patient presented with dyspnea on exertion. He was mildly bradycardic, his blood pressure was normal, his respiratory rate was 20, and he was not hypoxic on room air. His anemia and renal function had worsened, with a creatinine almost double his baseline. On 3/15/18, the patient was transfused PRBCs when his hemoglobin dropped below 7. His symptoms appeared to improve with a transfusion of PRBCs and additional diuretics. His renal function returned to baseline with careful diuretic administration. This patient met the criteria for admission and treatment in the telemetry unit given the presence of worsening CHF on imaging, increase of creatinine to twice the level of baseline, and hemoglobin less than 7. All told, the services provided from 3/13/18 through 3/16/18 were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned. | [
"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:: | a347a2aca8ecdc2c4f0ae64c44abe558 | ./data/processed/ca_cdi/summaries/19-6635.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The parent of a five-year-old male enrollee has requested authorization and coverage for Gammagard 20 gm infused every four weeks for one year, 40 units per dose for a total of 520 units. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that PANS represents sudden onset of psychiatric symptoms, typically consistent with obsessive-compulsive disorder, following infection with a number of agents, including group A streptococcus and mycoplasma. This represents a broader variation of PANDAS. An article by Calaprice and colleagues noted that the majority of practitioners utilized both short-term and long-term courses of antibiotics, intravenous immunoglobulin, particularly for patients with immunoglobulin G (IgG) deficiencies, plasmapheresis, psychotropic medications, and psychotherapy. Complementary and alternative medicines, including gluten-free diet and homeopathic medications, were also utilized. The authors noted that intravenous immunoglobulin therapy was reported to have been beneficial in reducing PANS symptoms for many patients, but was most beneficial, and most enduringly beneficial, for the subset with IgG deficiencies. This patient has a history of recurrent sinopulmonary infections, with reproducible laboratory evidence of common variable immune deficiency. He also meets criteria for PANDAS/PANS. Based on the current standard of care for patients with this constellation of disorders, monthly intravenous immunoglobulin therapy as prescribed is medically appropriate. Therefore, Gammagard 20 gm infused every four weeks for one year, 40 units per dose for a total of 520 units is medically necessary for the treatment of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 51fa0d3e613dcd742cf5427eb61a250f | ./data/processed/ca_cdi/summaries/19-6729.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 32-year-old female enrollee has requested authorization and coverage for Gamunex-C. 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 standard treatment of small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain, which can include several different classes of
medications. In small fiber neuropathy, current neuropathic pain treatment options are generally insufficient to relieve the pain substantially. Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. Intravenous immunoglobulin (IVIG) is a first-line treatment for immune-mediated neuropathies, such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy.
Erythromelalgia is a rare disorder that is characterized by erythematous, warm, painful extremities, which is often precipitated by cold conditions. The pathophysiology of erythromelalgia is incompletely understood. In a case study by Moody and colleagues, a patient with seronegative polyarthritis presented with a six-year history of erythromelalgia with recurrent bouts of painful erythema and triggered by minor trauma. Several medical therapies provided limited and inconsistent relief of her symptoms over many years. Treatment with intravenous immunoglobulin significantly decreased the frequency and severity of her symptoms. In this case, the patient has debilitating small fiber polyneuropathy with laboratory evidence of autoimmunity as well as clinical symptoms consistent with erythromelalgia. She has tried and failed conventional medical therapy. Based on the current medical evidence, patients with autoimmune small fiber neuropathy and erythromelalgia may improve clinically with intravenous immunoglobulin. Therefore, Gamunex-C is likely to be more beneficial than other available 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:: | 36e8df529fa9886b7424c990edfc1081 | ./data/processed/ca_cdi/summaries/20-6951.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 32-year-old female enrollee has requested authorization and coverage for Gamunex-C. 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 medical evidence supports the requested medication in this clinical setting. Schofield and Chemali noted, Immunoglobulin therapy has been used increasingly with significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are most often small fiber (autonomic and/or sensory) polyneuropathies. De Greef and colleagues noted that, Small fiber neuropathy is the most common cause of neuropathic pain in peripheral neuropathies. Patients experience excruciating pain, and currently available anti-neuropathic and other pain drugs do not relieve the pain substantially. Several open-label studies have suggested an immunological basis in small fiber neuropathy and have reported efficacy of treatment with intravenous immunoglobulin. Gamunex-C is an appropriate treatment in this patients case. All told, Gamunex-C is likely to be more beneficial than other available 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:: | 36e8df529fa9886b7424c990edfc1081 | ./data/processed/ca_cdi/summaries/20-6951.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 32-year-old female enrollee has requested authorization and coverage for Gamunex-C. 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 support for the requested medication in this patients case. The patient has been diagnosed with autoimmune small fiber neuropathy. As noted by Schofield and Chemali, Intravenous immunoglobulin therapy is U.S. Food and Drug Administration (FDA) approved for the immune-mediated peripheral nerve disorders Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. Immunoglobulin therapy has been used increasingly with significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are most often small fiber (autonomic and/or sensory) polyneuropathies. Intravenous immunoglobulin is used to treat a variety of autoimmune disorders, with a very good success rate. Thus, Gamunex-C is likely to be more beneficial than other available 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:: | 36e8df529fa9886b7424c990edfc1081 | ./data/processed/ca_cdi/summaries/20-6951.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found the minimally invasive SI joint fusion has not been demonstrated to result in superior health outcomes for the treatment of back pain when compared to standard available treatment options. Further, this patients medical records do not show any evidence of SI joint instability, fracture, or tumor, thus the criteria for SI joint fusion are not met. This patient has chronic back pain after previous lumbar fusion surgery. The pain is likely degenerative in cause. For these reasons, the requested SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 63ee7db7e7b11bc304bc3dca9853912c | ./data/processed/ca_cdi/summaries/17-4818.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found according to the coverage criteria by the International Society for the Advancement of Spine Surgery (ISASS), specific criteria must be met for all patients treated with minimally invasive SI joint fusion. The criteria require documentation of significant SI joint pain, SI joint pain confirmed with at least three physical examination maneuvers that stress the SI joint, confirmation of the SI joint as a pain generator with 75% or greater acute decrease in pain upon fluoroscopically guided diagnostic intra-articular SI joint block using local anesthetic, failure to respond to at least six months of non-surgical treatment consisting of non-steroidal anti-inflammatory drugs and/or opioids and one or more of the following: rest, physical therapy, SI joint steroid injection, and failure to respond means continued pain that interferes with activities of daily living and/or results in functional disability, as well as a record that additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been ruled out. Although this patient meets most of these criteria, there is insufficient evidence of a recent visual acuity score (VAS) score, three physical exam maneuvers demonstrating SI joint pain and confirmation by recent injection that resulted in greater than 75% pain relief. Therefore, the requested SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 63ee7db7e7b11bc304bc3dca9853912c | ./data/processed/ca_cdi/summaries/17-4818.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found this patient meets the criteria for a minimally invasive SI fusion. In the peer-reviewed medical literature, Polly and colleagues reported on a randomized controlled trial of 148 patients treated with minimally invasive SI joint fusion using triangular titanium implants or nonsurgical treatment with follow-up at one year. The authors concluded that this level one study showed that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. In another recent study, Whang and colleagues found that six month follow-up from this level one study showed that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruptions. Based upon a review of the recent literature, the requested minimally invasive form of SI joint fusion is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 63ee7db7e7b11bc304bc3dca9853912c | ./data/processed/ca_cdi/summaries/17-4818.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 42-year-old male enrollee has requested authorization and coverage for the prescription medication Skyrizi 150 mg syringe. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that according to the American Academy of Dermatology and the National Psoriasis Foundation, two leading authorities on psoriasis treatment, Skyrizi is a safe, effective and well-tolerated treatment of chronic plaque psoriasis. It is an immunoglobulin G (IgG) monoclonal antibody that neutralizes IL-17 and as such does not seem to have a significant effect on the pathogenesis of coronavirus infections. It is recommended as monotherapy for treatment of psoriasis. Methotrexate is an antimetabolite which can also work in treating psoriasis, but the efficacy and onset of action are not as good as compare with biologics. Cyclosporine is only a short-term treatment for a chronic disease and would not be appropriate. Acitretin has inferior efficacy and risk profile to some of the biologic treatments. There is sufficient support for the requested medication in this clinical setting. Therefore, the prescription medication Skyrizi 150 mg syringe is medically necessary for the treatment of this patient. | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | f25a63bbe8560373d59dfcc9c0f6fe7c | ./data/processed/ca_cdi/summaries/20-7072.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 65-year-old male who underwent laboratory testing on 8/11/20. The patient has requested reimbursement for magnetic resonance elastography performed on 10/07/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of the appeal and determination. The physician reviewer found that this patient has had elevated liver enzymes and imaging showing hepatomegaly with fatty infiltration, consistent with liver diseases including non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, and autoimmune hepatitis. The American Association for the Study of Liver Disease (AASLD) guidelines for non-alcoholic fatty liver disease recommend assessment for liver disease, including fibrosis and cirrhosis. Magnetic resonance elastography is one method for the assessment of liver disease; it has a higher technical success rate than ultrasound elastography, superior accuracy to serum liver function testing for the detection of significant liver fibrosis, and the ability to reliably differentiate between early and late stages of hepatic fibrosis. American Gastroenterological Association (AGA) Institute guidelines for the role of elastography in chronic liver disease state that magnetic resonance elastography has considerably higher diagnostic accuracy in ruling out cirrhosis in patients who do not have cirrhosis than ultrasound elastography, and AGA Institute guidelines for the role of elastography in the evaluation of liver fibrosis recommend using magnetic resonance elastography rather than ultrasound elastography for detection of cirrhosis in patients with a risk for non-alcoholic fatty liver disease and a higher risk of cirrhosis. Given that liver disease (including non-alcoholic fatty liver disease) was suspected in this patient with elevated liver enzymes and hepatic steatosis on imaging, and guidelines recommend assessment for liver disease in such cases with modalities including magnetic resonance elastography, magnetic resonance elastography was medically indicated for the evaluation of this patients elevated liver enzymes and hepatic steatosis. Therefore, magnetic resonance elastography performed on 10/07/20 was medically necessary for the evaluation of this patient.
| [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 0959a485d076278e25f25083003da1f8 | ./data/processed/ca_cdi/summaries/21-7247.jsonl | Insurer Denial Overturned | Medical Necessity |