Datasets:

Persius

/

hicric

like 1

Follow

Persius 1

Summary Reviewer 3 A 35-year-old female enrollee has requested reimbursement for (CPT code 86343) leukocyte histamine release test (LHR) dated on 10/20/15. The Health Insurer has denied this request indicating that the requested procedure are considered investigational for treatment of the enrollees chronic idiopathic urticariaThe physician reviewer found that there is a lack of support in the medical literature for LHR test in a clinical setting for the evaluation of chronic idiopathic urticarial (CIU). There is some utility of the LHR test as a research tool. Current evidence does not support routine clinical use of autologous serum skin testing or for LHR/basophil histamine responsiveness for the diagnosis of CIU. Chronic urticaria index is a test which consists of basophil (leukocyte) histamine release assay. If the test is positive (index greater than 10), the patient may have chronic autoimmune urticaria. The test is nonspecific. It measures only histamine release from the patients cells and compares it to a normal control. It does not measure antibodies or autoantibodies. Patients with a chronic form of urticaria with a positive functional anti-FceR test result likely have an autoimmune basis for their disease. A positive result does not indicate which autoantibody is present. This LHR test is usually combined with thyroid function, antithyroid microsomal titers, and peroxidase antibody titers. The result is reported as an index value. The reference range for a healthy non-CU population is less than 10. Values greater than or equal to 10 indicate that donor basophils were stimulated by patient serum to release histamine. The larger the value, the more histamine released. The CU index test (basophil histamine release test, AKA, Leukocyte histamine release test) has not been approved or cleared by the U.S. Food and Drug Administration. Although commercial assays are now available, the utility of testing for basophil histamine release and autoantibodies to the high-affinity IgE receptor or autoantibodies to IgE have not been established. Whether detection of basophil histamine release or autoantibodies identifies a clinically unique population or will lead to a change in management is also currently unclear. The American Academy of Allergy and Immunology guidelines for this test indicate it is primarily used in a research setting. All told, (CPT code 86343) leukocyte histamine release test (LHR) that was rendered on 10/20/15 was not likely to be more effective than the available standard methods of evaluating this patient. Therefore, for the reasons stated above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

15e99eccf29ae080d04796c6db7048a8

./data/processed/ca_cdi/summaries/16-4737.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer A 60-year-old female enrollee has requested reimbursement for OxyContin provided from 7/23/15 through 9/22/15. 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 the submitted documentation fails to demonstrate the medical necessity of the medication at issue in this patients case. The current medical evidence does not support the use of OxyContin in this clinical setting. The records do not show that non-opioid treatment options have been exhausted. The records have not documented behavior therapy for pain, despite research to support its use. Therefore, OxyContin provided from 7/23/15 through 9/22/15 was not medically indicated for the treatment of this patient. Therefore, the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

dcd94cb5de5513d01e3b38d315d555d6

./data/processed/ca_cdi/summaries/16-4531.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 63-year-old male enrollee has requested authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has been diagnosed with acute obstructive sleep apnea. The physician reviewer found that the patient is a 63-year-old male diagnosed with obstructive sleep apnea (OSA). He was diagnosed by a polysomnography in 2013 which indicated an apnea-hypopnea index (AHI) score of 56.5 consistent with severe OSA. The record documents failure of an extended trial of continuous positive airway pressure (CPAP) therapy. The patient underwent septoplasty and inferior turbinate reduction on 7/1/15. A subsequent sleep induced endoscopy indicated a palatal collapse. An uvulopalatopharyngoplasty was performed on 8/5/15. Another polysomnography was performed on 11/24/15 which showed an AHI score of 34.5. A follow up discussion with a provider noted options of upper airway stimulation as well as maxillo-mandibular osteotomy. The patient requests authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer denied this request indicating that the requested services are investigational for treatment of this patients medical condition. The current medical literature has not shown the superior efficacy of the requested services in this clinical setting. There is a lack of independent data regarding the effectiveness of this technique when compared to available standard therapies. At this time, further outcomes data, including those regarding long term effects, are needed before it is possible to support that implantation of cranial nerve stimulator is likely to be more effective than the available standard options. While there are some studies that show the benefits of this procedure, these outcomes are documented for selected patients. These are patients who have failed CPAP therapy, who show absence of concentric airway collapse on sleep endoscopy and who are not obese. This patient has not had a trial of CPAP therapy after having undergone nasal and palatal surgery. The documentation provided does not show that he has absence of concentric airway collapse. Lastly, he is obese based on the body mass index criteria. Therefore, in this patients case, the implantation of a cranial nerve stimulator is not likely to be more effective than the standard options available for the treatment of this patients medical condition. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

a7dd76e3cfc748e2f82b50f62e639bf2

./data/processed/ca_cdi/summaries/17-4854.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 63-year-old male enrollee has requested authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has been diagnosed with acute obstructive sleep apnea. The physician reviewer found that the patient is a 63-year-old male who has a history of snoring and obstructive sleep apnea (OSA). An initial baseline polysomnogram, performed in December 2013, confirmed moderate to severe OSA with an apnea hypopnea index (AHI) of 56.5 episodes per hour sleep. Oxygen saturation nadir was 87 percent. A follow-up titration study was performed confirming that bilevel positive airway pressure (BPAP) of 18 and expiratory positive airway pressure (EPAP) of 13 showed improvement of the patients symptoms, but the patient has become intolerant to the continuous positive airway pressure (CPAP) therapy. The submitted medical records document that the patient underwent procedures to improve symptoms of sleep disordered breathing including nasal surgery, septoplasty and inferior turbinate reduction. The surgical interventions improved and eliminated the majority of the patient's symptoms of snoring but did not improve all the sleep parameters. Drug-induced sleep endoscopy was performed on 7/1/15 under anesthesia. The report confirmed evidence that the patient does have a severe caudal collapse in addition to severe lateral collapse of the retropharyngeal palate. On 8/5/15, the patient underwent further surgical intervention which included suspension expansion pharyngoplasty. This was performed to improve the patients symptoms of airway obstruction. Postoperative subjective evaluation confirmed that the patient had some degree of improved sleep quality without velopharyngeal insufficiency or dysphagia. There is a report of a home sleep study performed following these interventions on 11/24/15 confirming that the AHI was at 34.5 episodes per hour of sleep and that the oxygen saturation nadir was 85%. The provider suggested upper airway stimulation to improve the patient's symptoms of OSA. The patient requests authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer denied this request as investigational for treatment of this patients medical condition. In this patients case, the requested services are not likely to be more effective than other forms of therapy for treatment of his OSA. The medical studies support implantation of cranial nerve stimulator in select patients. To be considered for surgical implantation of a cranial nerve stimulator, patients must have previously failed prior surgical management including uvulopalatopharyngoplasty, nasal reconstruction and other techniques in addition to therapy and failure with CPAP and mandibular advancement prostheses. Patients who are candidates for upper airway stimulation therapy must have undergone appropriate evaluations with polysomnogram, having reduced body mass index (BMI) of less than 32, along with objective upper airway evaluation measures documenting narrowing of the retro-palatal airway (Doghramji and Boon). The patient in this case, does not meet those criteria. The patients BMI is greater than 32. Moreover, there was no indication demonstrating that the patient has sustained any weight loss with prior medical management to reduce the BMI score below 32. Additionally, the drug-induced sleep endoscopy confirmed evidence of a very severe collapse which may be concentric. As such, implantation of cranial nerve stimulator is not likely to be more effective than other standard modalities available for treatment of this patients medical condition. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

a7dd76e3cfc748e2f82b50f62e639bf2

./data/processed/ca_cdi/summaries/17-4854.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 63-year-old male enrollee has requested authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has been diagnosed with acute obstructive sleep apnea. The physician reviewer found that the patient is a 63-year-old male who has a history of obstructive sleep apnea (OSA) and poor sleep. He is status post palate surgery and septoplasty. He underwent sleep endoscopy which revealed antero-posterior collapse at the velum and base of tongue. His Epworth sleepiness scale was reported at 4/24. He had a body mass index (BMI) of 34.6 when he underwent a polysomnography in 2013. That study also revealed an apnea-hypopnea index (AHI) score of 56.5. On 11/24/15, another sleep study was performed. The patients AHI score was document at 34.5. He failed continuous positive airway pressure (CPAP) therapy and was treated with bilevel therapy. The treating provider discussed implantation with cranial nerve stimulator as an option for treatment. The patient requests authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer denied this request as investigational for treatment of this patients medical condition. OSA is an increasingly prevalent clinical problem with significant effects on both personal and public health. CPAP has demonstrated excellent efficacy and low morbidity with long-term adherence rates approaching 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The STAR trial demonstrated that cranial nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA (Woodson, et al). However, these studies were performed in a subset of patients with OSA. Patients with concentric airway collapse, BMI greater than 32 and AHI less than 20 or greater than 50 were excluded. In this patients case, his BMI was 34.6 and his recent AHI was 34.5. All told, in this patients case, the current medical evidence does not support the superiority of implantation of cranial nerve stimulator over the available standard treatment options. 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]

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

a7dd76e3cfc748e2f82b50f62e639bf2

./data/processed/ca_cdi/summaries/17-4854.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 1 The patient is a 64-year-old male with a diagnosis of hypogonadism. His symptoms include decreased energy and libido, mood swings, sleepiness and changes in fat/muscles. His pre-treatment testosterone level was 208 in 2011. The patient has been treated with testosterone injections and Testopel. The patient is requesting reimbursement for Testopel implants provided on 1/21/16 and 5/26/16. The Health Insurer has denied this request as investigational. The use of Testopel is appropriate only for patients with an appropriate diagnosis of hypogonadism based on criteria recommended by national and international guidelines. Guidelines require measurement of two morning testosterone levels along with follicle-stimulating hormone/luteinizing hormone (FSH/LH) levels prior to initiation of therapy to identify the presence of and type of hypogonadism. In this case, the documentation submitted for review does not support that this was performed. In addition, patients who are on testosterone replacement should be monitored with laboratory work-up that includes testosterone, hematocrit, prostate-specific antigen (PSA), and lipid profile initially at frequent intervals and annually thereafter. Based on the clinical documentation submitted for review, the Testopel implants provided on 1/21/16 and 5/26/16 were 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 services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

b0433ee2806b0d028deb08501ac0b1d1

./data/processed/ca_cdi/summaries/17-5018.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 The patient is a 64-year-old male with hypogonadism manifested with low libido and low energy levels. His total testosterone was 208 in 2011. He was treated with Testopel pellets on 1/21/16 and 5/26/16. The patient is requesting reimbursement for Testopel implants provided on 1/21/16 and 5/26/16. The Health Insurer has denied this request as investigational. The Testopel implants provided on 1/21/16 and 5/26/16 were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Testopel is an alternative approved method of treating hypogonadism in an older male. It offers the advantages of maintaining a steady level of testosterone over many months. In addition, it eliminates the need for repeat daily or weekly or monthly dosing and is not dependent upon varying factor as to absorption like with testosterone gels and creams. Based on the clinical documentation submitted for review, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

b0433ee2806b0d028deb08501ac0b1d1

./data/processed/ca_cdi/summaries/17-5018.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 The patient is a 64-year-old male with a diagnosis of hypogonadism since 2011. In a letter dated 1/21/16, the provider notes the patients symptoms include decreased libido, decreased energy, mood swings, fat accumulation, sleepiness, and reduced muscle mass. The patient has been treated with Testopel since August 2015. On 3/16/16, his testosterone level was 187. The patient is requesting reimbursement for Testopel implants provided on 1/21/16 and 5/26/16. The Health Insurer has denied this request as investigational. The Testopel implants provided on 1/21/16 and 5/26/16 were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Testosterone replacement therapy (TRT) is recommended for older men with either low serum testosterone or low testosterone plus accompanying symptoms of hypogonadism. Serum testosterone levels of less than 300 is considered to be low, and testosterone levels of less than 250 is considered to be frank hypogonadism. Most experts support TRT for older men with frank hypogonadism and symptoms. TRT produces a number of established benefits in hypogonadal men, including increased muscle mass and strength, decreased fat mass, increased bone mineral density, and improved sexual function. In this case, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

b0433ee2806b0d028deb08501ac0b1d1

./data/processed/ca_cdi/summaries/17-5018.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer A 61-year-old female enrollee has requested authorization and coverage for Hizentra. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees nonfamilial hypogammaglobulinemia. The physician reviewer found that although the records indicate that the patient presents with recurrent infections, there is a lack of supporting documentation, such as chest x-rays, computed tomography of the sinuses or antibiotic logs, to confirm recurrent infections. In addition, the record does not demonstrate that the patient has been vaccinated with pneumococcal vaccines with pre and post vaccinations titer, which is evidence of persistent hypogammaglobulinemia. There is also no documentation that the patient has trialed prophylactic antibiotics or other therapies such as aggressive allergic rhinitis treatment, vaccination with conjugate pneumococcal vaccine or a trial of prophylactic antibiotics. The diagnosis of common variable immune deficiency (CVID) requires significantly reduced total serum concentrations of immunoglobulin, low immunoglobulin A (IgA) and/or immunoglobulin M (IgM), poor or absent response to immunization and exclusion of other immunodeficiency states or causes. In this case, the patient is reported to have low total IgG, but none of the other criteria of CVID (Chapel et al; Chapel and Cunningham-Rundles). Other causes of hypogammaglobulinemia have not been evaluated to include gastrointestinal or urinary loss of protein. Furthermore, the treatment of hypogammaglobulinemia with replacement immunoglobulin remains controversial. Most experts recommend treatment which includes immunization with conjugated pneumococcal vaccine (Prevnar 7 or 13), aggressive treatment of other conditions predisposing to recurrent sinopulmonary infections, increased vigilance and appropriate antibiotic therapy for infections, prophylactic antibiotics and intravenous immunoglobulin/subcutaneous immunoglobulin (IVIG/SCIG). In this case, the patients immune system has not been fully evaluated, there has not been aggressive treatment of her possible comorbid conditions. The documentation does not support that IVIG is safe and effective in this clinical setting. In sum, the documentation submitted for review fails to demonstrate a primary immunodeficiency related to antibody deficiency. Although there is evidence of hypogammaglobulinemia, the records lack a full evaluation of the patients immune system. As such, the request for Hizentra is not medically necessary for treatment of the patients medical condition. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

f60bffa469dada542de7fa4726f3b3b0

./data/processed/ca_cdi/summaries/16-4780.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 44-year-old female enrollee has requested authorization and coverage for the Intracept procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Khalil and colleagues performed a randomized controlled trial to compare the effectiveness of intraosseous radiofrequency ablation of the basivertebral nerve to standard care for the treatment of chronic low back pain. The authors noted maintenance of clinical improvement at two years following radiofrequency ablation of the basivertebral nerve. This trial included 140 patients with chronic low back pain that had been present for at least six months, with Modic Type 1 or 2 vertebral endplate changes. The patients were divided into two groups; half received the Intracept and the other half received standard care. The results showed clear superiority of radiofrequency ablation of the basivertebral nerves compared to standard care. In this case, the patient has chronic low back pain with Modic Type 1 vertebral endplate changes at L4-5 and L5-S1. The provider has tried other options, with documented failure. The requested Intracept procedure is known to have a high rate of success. Therefore, the requested Intracept procedure is likely to be more beneficial than any available standard therapy.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

2dcc36f7b6ffc6a6c084822e3a339085

./data/processed/ca_cdi/summaries/20-7137.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 44-year-old female enrollee has requested authorization and coverage for the Intracept procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Khalil and colleagues performed a prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. The authors concluded that minimally invasive radiofrequency ablation of the basivertebral nerve led to significant improvement of pain and function at three months in patients with chronic vertebrogenic related low back pain. Fischgrund and colleagues concluded that patients treated with radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited sustained clinical benefits in the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) pain scores, and maintained high responder rates at two years following treatment. Basivertebral nerve ablation appears to be a durable, minimally invasive treatment for the relief of chronic low back pain. She has failed to respond to nonsurgical management. Therefore, the requested Intracept procedure is likely to be more beneficial than any available standard therapy.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

2dcc36f7b6ffc6a6c084822e3a339085

./data/processed/ca_cdi/summaries/20-7137.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 44-year-old female enrollee has requested authorization and coverage for the Intracept procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a sparse amount of published clinical data to support the use of this treatment modality. An industry sponsored trial by Becker and colleagues involved 17 patients who were treated for refractory chronic low back pain. The authors concluded, aAblation of the basivertebral nerve for the treatment of chronic lumbar back pain significantly improves patientsa self-reported outcome early in the follow-up period; the improvement persisted throughout the one-year study period.a Fischgrund and colleagues performed a multicenter randomized control trial involving 225 patients with refractory low back pain. The authors noted, aPatients treated with radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited significantly greater improvement in Oswestry Disability Index (ODI) at three months and a higher responder rate than sham treated controls.a While there is a small amount of supporting data which suggests some short-term patient reported outcomes with the Intracept procedure, some of this data is industry sponsored. The single randomized controlled trial demonstrates some potential short-term benefit, but is lacking long-term efficacy and safety data. Clinical conclusions on this procedureas safety and efficacy require longer-term safety and efficacy data prior to accepting it as standard of care. Thus, the requested Intracept procedure is not likely to be more beneficial than any available standard therapy.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

2dcc36f7b6ffc6a6c084822e3a339085

./data/processed/ca_cdi/summaries/20-7137.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer A 57-year-old female enrollee has requested authorization and coverage for endovenous ablation therapy of incompetent vein. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees chronic venous insufficiency. The physician reviewer found that the documentation does not support the medical necessity of the requested endovenous ablation therapy of incompetent veins for treatment of this patients varicosities. The most recent evaluation documents that the patient is doing well and is without complaints or concerns and is using compression stockings as prescribed. Therefore, there is no indication for additional treatments. Accordingly, the requested endovenous ablation therapy of incompetent vein is not supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

1b717181f3abeb0957019955a9d60851

./data/processed/ca_cdi/summaries/18-6380.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer A 59-year-old male enrollee has requested authorization and coverage for cryosurgical ablation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for treatment of the enrollees thymoma. The physician reviewer found that thymoma is the most common primary tumor of the anterior mediastinum and often recurs after initial surgical resection. In patients with recurrent disease and inability to perform further resections due to lack of pulmonary reserve or unresectability of the metastatic disease, cryotherapy may serve as a useful adjunct to chemotherapy and radiation therapy. A recent review article by Abtin and colleagues noted that percutaneous cryoablation shows promise as a safe and effective treatment modality for recurrent thymoma. The relative rarity of this diagnosis limits the availability of large scale, prospective clinical trials. However, current medical literature cites a high success rate for long-term tumor ablation. A recent review article by Zhang and colleagues noted that, In conclusion, cryotherapy is a safe and efficient method for the treatment of unresectable malignant thymoma. Thus, the requested cryosurgical ablation is medically necessary for 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

9c1d2eac5d94bef62ec690b8fdf6bf8d

./data/processed/ca_cdi/summaries/17-6150.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer A 51-year-old male enrollee has requested reimbursement for home healthcare services which include intravenous infusion of ceftriaxone, Benadryl, associated supplies and office visits with Miguel Gonzalez, MD from dates of service 9/11/15 through 12/09/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient has a long history of a variety of non-specific complaints. The clinical evidence and the laboratory studies provided for review do not support a diagnosis of any tick borne diseases or Lyme disease. The Borrelia burgdorferi serologies completed in March 2015 are negative. In spite of this, the provider ordered intravenous ceftriaxone. This drug is recommended for Lyme disease associated arthritis, carditis or neurological disease. The records do not document that this patient had the rash typical of early Lyme disease, and his reported symptoms are not suggestive of this diagnosis. In sum, home healthcare services which include intravenous infusion of ceftriaxone, Benadryl, associated supplies and office visits with Miguel Gonzalez, MD from dates of service 9/11/15 through 12/09/15 were 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

d22337b0c9205c3d28e484fd35cca6bc

./data/processed/ca_cdi/summaries/16-4399.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer A 59-year-old male enrollee has requested authorization and coverage for Testim (testosterone gel 1%). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypogonadism. The physician reviewer found that low testosterone can lead to complications including reduced libido, erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis, depressed mood and fatigue (Dandona and Rosenberg). For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL (Nieschlag, et al). The general target level for testosterone ranges from 350 to 750 ng/dL, which is the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal and the dose of testosterone replacement therapy should be adjusted accordingly (Rivas, et al). Given these findings, the requested Testim (testosterone gel 1%) is medically necessary for treatment of this patients hypogonadism. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

ab8e4aa9c2b27a657f64ab1679ba8652

./data/processed/ca_cdi/summaries/19-6631.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 1 The parent of a two-year-old male enrollee has requested reimbursement for FirstStepDX Plus chromosomal microarray analysis. 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 array-based comparative genomic hybridization has become standard of care to investigate children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies. Until recently, it was a diagnostic test that was employed when the first-line investigation of karyotype (chromosome analysis) returned normal; over the last several years it has emerged as a first-line investigation. This test has become an important and mainstream tool in the practice of clinical genetics. Its diagnostic utility had been convincingly demonstrated. Data have now emerged showing that actionable findings from chromosomal microarray justify its use. In sum, FirstStepDX Plus chromosomal microarray analysis 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

82bd83298eabd5ee30d7d44c9a63388d

./data/processed/ca_cdi/summaries/16-4537.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 The parent of a two-year-old male enrollee has requested reimbursement for FirstStepDX Plus chromosomal microarray analysis. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the patient is a two-year-old male who was born at 38 weeks gestation following a pregnancy significant for hyperemesis requiring frequent antiemetic therapy and preterm labor at 32 weeks gestation requiring modified bed rest. He suffered an event prior to discharge characterized by choking followed by desaturation to the 20s with subsequent resuscitation efforts. Persistent transaminitis lead to liver biopsy at eight weeks of age and a diagnosis of giant cell hepatitis. He had difficulties with feeding, colic, and delayed achievement of usual gross motor milestones. He currently receives physical therapy with ongoing gross motor delays. Neurologic examination in March 2015 revealed increased deep tendon reflexes in his lower extremities, intermittent exophoria bilaterally, moderately decreased tone globally, inability to stand unassisted, and microcephaly. At that time, chromosomal microarray testing and fragile X testing were performed. The Health Insurer has denied reimbursement for FirstStepDX Plus chromosomal microarray analysis. Per the Health Insurer, FirstStepDX Plus chromosomal microarray analysis was investigational for the evaluation of this patient. The current medical evidence supports the services at issue in this patients case. Use of chromosomal microarray testing now plays a central role in the evaluation and diagnosis of children with global developmental delay, cognitive delay, and autism spectrum disorders (ASD). Use of buccal sampling is an acceptable means of obtaining material for study. According to the literature, when coupled with a chromosomal microarray that contains single nucleotide polymorphic probes, analysis of buccal cells can maximize a clinicians opportunity to detect cytogenetic mosaicism. Based on the literature and current standard of practice, the services at issue were likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

82bd83298eabd5ee30d7d44c9a63388d

./data/processed/ca_cdi/summaries/16-4537.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 The parent of a two-year-old male enrollee has requested reimbursement for FirstStepDX Plus chromosomal microarray analysis. 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 CMA is increasingly utilized for genetic testing of individuals with unexplained developmental delay/intellectual disability, autism spectrum disorders, or multiple congenital anomalies. CMA offers a much higher diagnostic yield for genetic testing of patients with unexplained developmental delay/intellectual disability, autism spectrum disorder, or multiple congenital anomalies than the previous standard testing with G-banded karyotype, primarily because of its higher sensitivity for submicroscopic deletions and duplications. Available evidence strongly supports the use of CMA in place of G-banded karyotyping as the first-tier cytogenetic diagnostic test for patients with developmental delay/intellectual disability, autism spectrum disorders, or multiple congenital anomalies. Given that the standard of care is now CMA, the FirstStepDx Plus chromosomal microarray was likely to have been of greater benefit than other methods of evaluation. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

82bd83298eabd5ee30d7d44c9a63388d

./data/processed/ca_cdi/summaries/16-4537.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer A 42-year-old female enrollee has requested authorization and coverage for Remodulin (treprostinil) injections. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees pulmonary arterial hypertension. The physician reviewer found that there is support in the medical literature and guidelines for the requested medication in this clinical setting. Remodulin (treprostinil) belongs to the Prostacyclin analog drug class. Based on recommendations from the 2015 European Society of Cardiology (ESC)/ European Society of Cardiology (ERS) guidelines for the diagnosis and treatment of pulmonary hypertension, Prostacyclin analogues are appropriate therapy in particular combination with phosphodiesterase inhibitors and endothelin receptor antagonists. In a study by Simonneau and colleagues, the effects of treprostinil in PAH were assessed in a randomized clinical trial. These patients showed improvements in exercise capacity, hemodynamics and symptoms. Some of the evidence from combination therapy indicate a reduced risk of clinical worsening and other significant endpoints. According to the submitted record, this patient has stabilized with reductions in pulmonary artery pressures and symptoms on her current regimen of combination therapy, which includes subcutaneous infusions of treprostinil. For these reasons, Remodulin (treprostinil) injections are medically necessary for treatment of this patients medical condition. Therefore, based on the above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

4921dcbd3ea00478668ed5397d4d0196

./data/processed/ca_cdi/summaries/18-6232.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer A 43-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) therapy from 10/23/15 through 11/24/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is support for a portion of the services at issue in this clinical setting. The patient began TMS therapy on 8/21/15 with a PHQ9 of 27/27, indicating a severe level of depression. Over the course of TMS treatment, the documentation noted that her depression lifted, as reflected by her subsequent PHQ9 scores and subjective reports. By 10/23/15, she reported significant improvement with a PHQ9 of 5/27. On 10/7/15, she received TMS session #30, and on 10/28/15 she received TMS session #6 of tapering. The documentation noted that the Health Insurer had approved 30 TMS sessions with an additional six for tapering. The sessions from 10/23/15 through 10/28/15 were medically necessary, as she showed improvement while in active treatment. However, the services from 10/29/15 through 11/24/15 were not medically necessary for treatment. There is a lack of evidence, in the body of literature, to support the medical necessity of continued long term TMS treatment, in this patients case. As such, the TMS sessions from 10/23/15 through 10/28/15 were medically necessary but not thereafter. Therefore, for the reasons stated above, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

ea62732b5a49326d9dcb5800b739ced8

./data/processed/ca_cdi/summaries/17-4803.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer A 39-year-old female enrollee has requested authorization and coverage for Simponi injections 100 mg/ml. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriatic arthropathy. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. The records document a history of psoriasis and psoriatic arthritis. In this case, the recent notes indicate that the patient was not currently taking methotrexate as prescribed since at least November 2016. Per the records, she had responded to methotrexate and Otezla in the past and had stopped Simponi at that time. There is currently a lack of guidelines or large randomized controlled trials which recommend the use of a tumor necrosis factor inhibitor, like Simponi, in combination with Otezla. The records fail to demonstrate that she has failed treatment with a tumor necrosis factor inhibitor in combination therapy with methotrexate, or Otezla with methotrexate. As such, the request for Simponi in combination with Otezla is not medically necessary. Thus, the requested Simponi injections 100 mg/ml are not medically indicated for the treatment of this patient. Thus, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

78913602ca822c262235ca570b37afd7

./data/processed/ca_cdi/summaries/17-4913.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer The patient is a 20-year-old male with a past psychiatric history of intermittent explosive disorder and attention deficit hyperactivity disorder. The patient has requested reimbursement for acute psychiatric inpatient treatment provided from 11/03/21 through 11/13/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is this subject of this appeal and determination. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement and recovery status. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient met the criteria for acute psychiatric inpatient services provided from 11/03/21 through 11/13/21. For dimension 1, risk of harm, the records support a score of 5. This dimension assesses potential for harm to self or others, or having harm inflicted upon them. The patient was noted to be unsafe outside of the community. He had poor insight, erratic judgment, and was described as highly explosive. He was involuntarily committed to the inpatient psychiatric facility during the period under review. The patient had been endorsing homicidal ideation. He was described as impulsive. For dimension 2, functional status, the records support a score of 5. This dimension assesses the degree to which a patient is able to fulfill social responsibilities, to interact with others, maintain physical functioning, as well as a patientas capacity for self-care. The records indicate that the patient had been threatening others, was argumentative, was disruptive in the milieu, had engaged in property destruction, and was easily agitated and impulsive. He was isolative from family members. At the time of admission, the patient self-reported that he engaged in property destruction. He also engaged in threatening behavior. For dimension 3, medical, addictive, and psychiatric comorbidity, the records support a score of 2. This dimension assesses the potential complications in the course of illness due to level of acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder in addition to the presenting disorder. Although the patient denied substance use, his urine toxicology on admission was positive for cannabis. For dimension 4A, level of stress in the recovery environment, the records support a score of 4. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patientas recovery environment is highly stressful due to significant conflict with family members as a result of his irritability and poor anger control. The family feels as though they awalk on eggshellsa due to the patientas behavior. For dimension 4B, level of support in the recovery environment, the records support a score of 2. This dimension assesses the resources which enable the individual to maintain health and role functioning, such as availability of adequate material resources, relationships with family members, and the availability of friends, employers, teachers, or others. According to the records, the patientas mother appears to be supportive as evidenced by her willingness to engage with the patientas treatment providers by providing them information about the patient. The patient described his family as supportive. For dimension 5, treatment and recovery history, the records support a score of 5. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. In this patientas case, prior treatment has included weekly psychotherapy, regular psychiatric visits, and psychotropic medication for the last four years. In addition, the records noted one previous inpatient psychiatric admission for similar issues, and he attended a partial hospital program. He had also not responded to the structure and containment of the current hospital milieu. Despite this, the patientas symptoms persisted, and his functional ability has shown no significant improvement. Per the records, the patient has had negligible response to treatment. For dimension 6, engagement and recovery status, the records support a score of 5. This dimension considers a patientas understanding of illness and treatment and ability or willingness to engage in the treatment and recovery process. According to the records, the patient had been refusing medication. He minimized his symptoms and had little insight into his mental illness. These findings give the patient a composite score of 28, which is consistent with Level 6 Medically Managed Residence Services. Per LOCUS, the patientas scores of 5 for risk of harm and functional status also support treatment at Level 6 Medically Managed Residence Based Services level of care. Therefore, acute psychiatric inpatient treatment provided from 11/03/21 through 11/13/21 was medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

98ec08412ee2e1f12ccd93f68611491f

./data/processed/ca_cdi/summaries/21-7411.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer The patient is a 65-year-old male with a history of seizures due to epilepsy for which brain surgery was performed in March 2015. In 2015, he reportedly sustained a subarachnoid hemorrhage. He became dependent on mechanical ventilation and received a tracheostomy. He received an enterostomy tube for feeding. The patient was transferred to a skilled nursing facility (SNF) on 7/9/15. On 9/12/15, he was transferred back to the hospital and on 9/25/15, he returned to the SNF. On 1/10/16, he returned back to the hospital for unspecified reasons. On 1/30/16, he returned to the SNF with diagnoses including chronic respiratory failure, tracheostomy, epilepsy, hyperlipidemia, chronic obstructive pulmonary disease (COPD), hyperglycemia, polyneuropathy, cerebellar ataxia, alcoholic liver disease, alcohol abuse, hypothyroidism, hypertension, gastroesophageal reflux disease (GERD), and urinary retention. He was receiving gastrostomy tube feeds. He had an indwelling urinary catheter. A pain management interview noted that the patient is alert, confused and disoriented. He was noted to be non-verbal. There was no pain at present. On examination, he had 2+ pitting edema. He required total assistance for self-care. On 3/11/16, physical therapy was discontinued. On 5/20/16, a consultation note indicated past history of hyperlipidemia, alcohol abuse and respiratory failure. He was alert and in no acute distress. There was atrophy and contractures. He was non-ambulatory. A left heel blister was noted. On 6/30/16, restorative nursing was ordered by the provider for passive range of motion of the upper and lower limbs. On 8/17/16, oral Levaquin antibiotics were ordered for the urinary tract infection. On 8/19/16, ertapenem intravenous (IV) antibiotics were ordered for the urinary tract infection. The providers notes from 9/2/16 through 10/14/16 document a stable clinical condition, awake neurological status, and review of lab test results. On 9/28/16, he was sent to the acute hospital for a change of gastrostomy tube. On 10/14/16, the provider noted that there was no fever or bleeding. The patient was tolerating tube feeds. Exam noted that he was awake. There was 1+ edema. On 10/16/16, Macrobid was ordered for a urinary tract infection. On 10/20/16, ertapenem IV antibiotics were ordered for the urinary tract infection. A letter from the provider dated 4/12/17 stated that the patient required respiratory support, multiple lab tests, seizure prophylaxis, tracheostomy care and additional medical interventions. The patients representative has requested reimbursement for the inpatient services provided at Goldstar and Beachwood Rehabilitations Centers provided from 10/30/15 through 1/10/16 and from 4/22/16 through 1/11/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary.Functional impairments due to acquired brain insults can improve with time including after subarachnoid hemorrhage (Navi, et al; Turner-Stokes, et al). The role of inpatient rehabilitative care for patients with significant functional deficits following acquired brain insults is relatively well-established in the medical literature (Langhorne, et al). In the present case, the patient was hospitalized with an acquired brain insult, due to various factors including surgery for a seizure disorder and subarachnoid hemorrhage. He eventually became alert, but non-verbal and confused. There are no indications in the available records that the patient was able to participate in therapies in a meaningful manner at any time during the time period under review, or that he made or was expected to make any significant functional progress. The records document that the patient had atrophy and contractures, was totally dependent for all self-care, and he received passive range of motion by restorative nursing. The services provided were on a long-term, maintenance basis, which are considered custodial in nature. Given these findings, the inpatient services provided at Goldstar and Beachwood Rehabilitations Centers provided from 10/30/15 through 1/10/16 and from 4/22/16 through 1/11/17 were not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

d1f5f27a421fe1e9d257b7a8fc1113ef

./data/processed/ca_cdi/summaries/18-6186.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 65-year-old male enrollee has requested reimbursement for collagen crosslink testing performed on 7/11/15. 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 Osteoporosis is a condition of thinning of the bones which leads to increased risk of fracture. Bone mineral density assessment, via dual-energy x-ray absorptiometry (DEXA), is the standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients who are treated with antiresorptive agents. The medical evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. There is sufficient support for the services at issue in this clinical setting. All told, collagen crosslink testing was likely to have been superior over other treatment options. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

04a8c5c39bf99a6308aa23228012a04a

./data/processed/ca_cdi/summaries/16-4381.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 65-year-old male enrollee has requested reimbursement for collagen crosslink testing performed on 7/11/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting. The National Osteoporosis Foundation approves the use of biochemical markers of bone turnover as a tool to investigate causes of osteoporosis and then as a follow-up test to monitor response and compliance with antiresorptive therapy. This test may be done to assess response to therapy sooner than the one- to two-year follow-up dual-energy x-ray absorptiometry (DEXA) scan study that quantifies response in bone density measurements. In this case, the test provided information regarding the response to Prolia therapy. The significant reduction of the C-telopeptide level is consistent with excellent response to antiresorptive therapy with Prolia. In sum, collagen crosslink testing performed on 7/11/15 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

04a8c5c39bf99a6308aa23228012a04a

./data/processed/ca_cdi/summaries/16-4381.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 65-year-old male enrollee has requested reimbursement for collagen crosslink testing performed on 7/11/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the services at issue. This patient has received Prolia. In this clinical setting, a dual-energy x-ray absorptiometry (DEXA) scan is appropriate to monitor therapy. The value of monitoring therapy with the use of biochemical markers of bone turnover is controversial. This is a test that can be variable and subject to timing, dietary intake and lack of assay standardization. In sum, collagen crosslink testing performed on 7/11/15 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

04a8c5c39bf99a6308aa23228012a04a

./data/processed/ca_cdi/summaries/16-4381.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer The patient is a 61-year-old man with low back pain and radiating symptoms. The patient has requested authorization and coverage for spinal 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. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. In this case, the patient has mechanical low back pain with radiating symptoms to the thighs. Although his examination was normal, imaging showed significant spondylolisthesis. The medical literature indicates that patients with mechanical back pain associated with spondylolisthesis have superior outcomes when treated with lumbar fusion. Therefore, the requested spinal surgery is medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

1fca0ec232e1ca762a52e5c251a58709

./data/processed/ca_cdi/summaries/21-7394.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer The parent of a three-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient mental health treatment for children and adolescents provided from 12/31/18 through 6/29/19. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 2 due to the patients history of impulsive behaviors. In terms of functional status, the records support a score of 2. The patient has had deterioration in expected level of functioning in relationships with peers, adults and family, and he is struggling with serious daily behavioral issues. In terms of comorbidity, the records support a score of 1. The patient does not have medical problems or substance use. With regards to level of stress of the recovery environment, the records support a score of 3. The patient has problematic issues with family relationships. In terms of level of support of the recovery environment, the records support a score of 2. The patients family actively participates in treatment, although their relationship appears to be strained. With regards to resiliency and treatment history, the records support a score of 3 due to recent minimal progress in the intensive outpatient program. In terms of acceptance and engagement of the child, the records support a score of 3. The patient participates minimally. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 18. The score correlates with intensive outpatient program services. Therefore, intensive outpatient mental health treatment for children and adolescents provided from 12/31/18 through 6/29/19 was and is medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

0e486c2b6205cca7e3d19c2d1a6e6375

./data/processed/ca_cdi/summaries/19-6784.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 1 A 25-year-old female has requested authorization and coverage for intravenous ceftriaxone. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested medication in this clinical setting. There is a lack of evidence that this patient has any infection. The records do not describe a tick bite or the development of a rash at the site of the bite. Her symptoms are non-specific. There is also no evidence for either Babesia or Brucella infection. One month of ceftriaxone is accepted therapy for Borrelia infection if cardiac disease is present, neurological involvement is documented or joint involvement is found. In this case, none of these forms of infection is present. The notes state she is being treated for neurological infection, but there is no evidence to support this diagnosis. The current medical evidence has not demonstrated that greater than 28 days of therapy is of benefit for patients with Lyme disease, and the records do not demonstrate that she has Lyme disease. In sum, intravenous ceftriaxone is not likely to be superior over other treatment options. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

c5b3e14ff808eb2ef281a50620e08d80

./data/processed/ca_cdi/summaries/17-4873.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 25-year-old female has requested authorization and coverage for intravenous ceftriaxone. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the medical evidence does not support the requested medication in this patients case. The patients symptoms are non-specific, and the examination findings are non-focal. The laboratory examination was negative for Borrelia infection. The diagnosis of late stage neuroborreliosis or Lyme arthritis has not been established. If the diagnosis of neuroborreliosis was established, the standard of care is one four-week course of intravenous ceftriaxone. Repeat or longer term courses of antibiotic have not been shown to be efficacious. The peer-reviewed literature does not demonstrate evidence for the requested medication in this clinical setting. All told, the requested intravenous ceftriaxone is not likely to be superior over other methods of treating this patient. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

c5b3e14ff808eb2ef281a50620e08d80

./data/processed/ca_cdi/summaries/17-4873.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 25-year-old female has requested authorization and coverage for intravenous ceftriaxone. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested medication in this clinical setting. She underwent 28 days treatment with intravenous ceftriaxone following oral therapy. The most recent guidelines for the treatment of Lyme disease do not recommend prolonged or repeated therapy for the same episode of Lyme. Per the medical evidence, central nervous system Lyme disease should be treated with a duration of 14 days, with a range of 10 to 28 days. This patient was treated with two weeks of ceftriaxone followed by another 28 days. The medical evidence does not support the requested medication in this case. Thus, the requested intravenous ceftriaxone is not likely to be superior over other treatment alternatives. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

c5b3e14ff808eb2ef281a50620e08d80

./data/processed/ca_cdi/summaries/17-4873.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer This patient is a six-year-old male who was diagnosed with acute flaccid myelitis in October 2018. The patientas parent has requested authorization and coverage for RT300 FES Rehabilitation Therapy System. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of this patient. The physician reviewer found that the medical literature provides sufficient evidence that supports the benefit of RT 300 FES system over other standard, traditional therapy modalities alone in achieving better outcomes with strengthening, reduced spasticity and improved quality of life. The indications for the RT300 FES Rehabilitation Therapy System for this patient with acute flaccid myelitis and paraplegia are valid and supported by current medical research. These indications include prevention of muscle disuse atrophy, relaxation of muscle spasms, improving blood circulation, prevention of osteoporosis, maintaining or increasing range of motion, prevention of contractures, and cardiac and pulmonary deconditioning. The functional status, the medical history of the patient with secondary complications of the acute flaccid myelitis paraplegia, the prognosis of his injury and neurological level of involvement support the use of this modality. Therefore, RT300 FES Rehabilitation Therapy System is medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

c675efab9945cd0001916c206bf026ad

./data/processed/ca_cdi/summaries/21-7234.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 1 A 41-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/06/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. All told, breast tomosynthesis performed on 11/06/15 was likely to have been more efficacious than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

f3c57f3a702f2c22ac221ebb9f96e470

./data/processed/ca_cdi/summaries/16-4410.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 2 A 41-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/06/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.The physician reviewer found the current medical evidence supports the services at issue in this patients case. Breast tomosynthesis has been demonstrated to be of particular benefit in women with extremely dense and heterogeneously dense tissue. The tomographic nature of this technique often allows radiologists to separate dense underlying glandular elements from architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of more benefit to this patient than if she had 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

f3c57f3a702f2c22ac221ebb9f96e470

./data/processed/ca_cdi/summaries/16-4410.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 3 A 41-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/06/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.The physician reviewer found breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, she has breasts that have been described as being 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, breast tomosynthesis performed on 11/06/15 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

f3c57f3a702f2c22ac221ebb9f96e470

./data/processed/ca_cdi/summaries/16-4410.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 1 A 20-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 8/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that Polymerase chain reaction testing is an appropriate test for chlamydia, gonorrhea, and trichomonas, all of which should be tested for as part of a sexually transmitted disease evaluation. In this case, it appears the patient was tested for trichomonas, but there are no records to indicate testing for chlamydia and gonorrhea. In addition, multiple polymerase chain reaction tests were performed for various vaginal organisms, some of which do not even cause infection. The records noted that testing was performed for candida species, lactobacillus species, atopobium vaginae, megasphaera species, and Gardnerella vaginalis quantification. Polymerase chain reaction testing for these organisms is not standard of care. Standard testing for evaluation of a vaginal discharge includes assessing the symptoms, assessing the appearance of the discharge, pH testing of the vaginal fluid, examination of the discharge under the microscope, and sometimes DNA probes or cultures. There are no records to indicate that these standard evaluations and diagnostic tests were done. In sum, polymerase chain reaction test for trichomonas was likely to have been more effective than other methods of evaluating this patient. However, the superior efficacy of the remaining tests has not been established.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

c117b373b36a20df029673e21f5bd68d

./data/processed/ca_cdi/summaries/19-6748.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 20-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 8/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Polymerase chain reaction testing has been compared to traditional clinical testing for vaginitis. The literature supports the use of polymerase chain reaction testing because it has resulted in significantly higher sensitivity and negative predictive value than clinician diagnosis or in clinic testing. The test may also be superior for detecting more than one cause for vaginitis. The services at issue were appropriate in this patients case. Therefore, polymerase chain reaction testing performed on 8/14/18 was likely to have been more effective than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

c117b373b36a20df029673e21f5bd68d

./data/processed/ca_cdi/summaries/19-6748.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 20-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 8/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the medical evidence has not demonstrated the superior efficacy of vaginitis panel testing using polymerase chain reaction technology. Although these methods have high sensitivity and specificity, including a shorter turn-around time than culture, the testing offers no proven benefit over standard culture in symptomatic women. Furthermore, there is a lack of evidence on the clinical utility and impact of polymerase chain reaction testing for vaginitis. There is a lack of studies showing that this testing leads to better patient management decisions or better health outcomes. Studies of diagnostic accuracy alone are inadequate, especially because most symptomatic women can be diagnosed with a standard work-up and/or a trial of empiric therapy. Thus, polymerase chain reaction testing performed on 8/14/18 was not likely to have been superior over other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

c117b373b36a20df029673e21f5bd68d

./data/processed/ca_cdi/summaries/19-6748.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer A 30-year-old female enrollee has requested reimbursement for air ambulance transportation provided on 12/20/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who has a history of spinal muscular atrophy. The physician reviewer found that this patient has a diagnosis of spinal muscular atrophy. She had acute respiratory failure on 11/16/17, necessitating admission to Cottage Health Hospital. During the course of her admission, the patients family made inquiries regarding transferring the patient to a facility with more expertise in treating patients with spinal muscular atrophy. By 12/19/17, the patient had been weaned from a ventilator to a tracheostomy collar. The patients family requested the patient be transferred to Rutgers University Hospital to the care of a specialist in spinal muscular atrophy where studies had been conducted to determine appropriate respiratory protocol and management strategies. However, the records do not demonstrate that this patient required emergent air ambulance transportation. The patient was hemodynamically stable. She had already been weaned to a tracheostomy collar. Although the provider at Rutgers University Hospital had conducted research with spinal muscular atrophy patients, there is a lack of evidence to support that this patient required a higher level of care at the time of her transfer. It appears the transfer was initiated at the request of the patients family. The documentation submitted does not support that this patient required emergent air ambulance transportation to receive medically necessary higher level of care at the closest hospital capable of providing such services. Thus, air ambulance transportation provided on 12/20/17 was not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

9360de69868b598c9006cde2090ce302

./data/processed/ca_cdi/summaries/18-6402.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 An 18-year-old male has requested reimbursement for Anser IFX testing performed on 7/09/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found there is sufficient support for the services at issue in this clinical setting. This patient was losing response to the biologic treatment. Rather than empirically dose escalate the patient, the provider recommended Anser IFX testing. This testing determined that dose escalation would be futile. This allowed for a rapid switch to another more beneficial agent. In sum, Anser IFX testing provided on 7/09/15 was likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

208aab3f45926b85ddffd34b3e58bafc

./data/processed/ca_cdi/summaries/16-4668.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 An 18-year-old male has requested reimbursement for Anser IFX testing performed on 7/09/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the current medical evidence has not demonstrated the superior efficacy of the services at issue. The use of Anser IFX testing to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear Remicade levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. Although loss of response to infliximab is common, there were a lack of standard guidelines defining a therapeutic strategy at the time of testing. A systematic review by Yarur and colleagues noted that future prospective controlled studies are needed, especially considering that anti-tumor necrosis levels are influenced by several variables that can fluctuate over time and among individuals. In sum, Anser IFX testing performed on 7/09/15 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

208aab3f45926b85ddffd34b3e58bafc

./data/processed/ca_cdi/summaries/16-4668.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 An 18-year-old male has requested reimbursement for Anser IFX testing performed on 7/09/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well-controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement. It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Thus, Anser IFX testing performed on 7/09/15 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

208aab3f45926b85ddffd34b3e58bafc

./data/processed/ca_cdi/summaries/16-4668.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 1 A 66-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 8/10/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung adenocarcinoma. The physician reviewer found that Adenocarcinoma of the lung should be tested for certain molecular abnormalities, including ALK, EGFR and ROS-1. Each of these has a therapeutic implication. In this case, EGFR and ALK testing were done on the initial tissue biopsy, so it is not necessary to check these on Guardant360 assay. The other use of Guardant360 assay is to look for a target at which therapy can be directed. Thus far, such use has not been shown to be clinically beneficial for the vast majority of patients. A randomized study by Le Tourneau and colleagues failed to demonstrate that choosing therapy based on molecular profiling was superior to choosing therapy based on conventional judgment. Therefore, Guardant360 testing 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

a731ec01ecc23d5e22cefdbc8b5e11ac

./data/processed/ca_cdi/summaries/19-6579.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 66-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 8/10/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung adenocarcinoma. The physician reviewer found that molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection beyond standard testing, such as EGFR. The National Comprehensive Cancer Network guidelines advise broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. In sum, Guardant360 testing performed on 8/10/17 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

a731ec01ecc23d5e22cefdbc8b5e11ac

./data/processed/ca_cdi/summaries/19-6579.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 66-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 8/10/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung adenocarcinoma. The physician reviewer found that the therapy of advanced non-small cell lung cancer has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in certain adenocarcinomas. The mutations are more common in those who have never smoked. Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of non-small cell lung cancer has significantly expanded in the past two to three years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. Patients on targeted therapy may develop resistance to erlotinib, and this may be appreciated at the genetic level by recognition of new mutations or amplifications in parallel signal transduction pathways. The Guardant360 test is a liquid biopsy that analyzes patient plasma for mutations in a panel of 70 genes. Von Hoff and colleagues performed a clinical study directly comparing the use of targeted agents with conventional chemotherapy approaches. The study involved 86 patients, and the progression-free survival on regimen selected by molecular profiling was compared to the progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has significant results for patients with stage IV tumors. In this patients case, the results from molecular profiling may offer a rational selection of the next regimen. Thus, Guardant360 testing performed on 8/10/17 was likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

a731ec01ecc23d5e22cefdbc8b5e11ac

./data/processed/ca_cdi/summaries/19-6579.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer A 33-year-old female enrollee has requested reimbursement for Fragile X mental retardation 1 laboratory testing (81243) performed on 8/09/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that Prenatal screening for fragile X syndrome is not currently a part of universal screening in terms of genetic testing for routine prenatal care. The testing is performed to identify individuals at risk for conceiving a child with clinical manifestations of the disorder. Per the American College of Obstetricians and Gynecologists (ACOG), screening for fragile X syndrome is offered in women after a careful assessment of the family history is performed to identify individuals with sufficient likelihood of premutation or full mutation carrier status to warrant such screening. The following is used as criteria for such screening: individuals seeking reproductive counseling who have a family history of fragile X syndrome (confirmed premutation or full mutation of FMR1 gene) or intellectual disability of undetermined etiology; individuals of either sex with intellectual disability or developmental delay of undetermined etiology, or autism; young women with elevated levels of follicle-stimulating hormone, especially with a family history of premature ovarian insufficiency (menopause before age 40), fragile X syndrome, or a relative of either sex with intellectual disability of undetermined etiology; and individuals with late-onset intention tremor or ataxia (usually after age 50), especially with a history of infertility, family history of movement disorders, fragile X, or intellectual disability of undetermined etiology. Universal screening is not offered, in part, due to the difficulty in predicting phenotype in offspring of low-risk women (women with a negative personal and family history) with a premutation. Given the clinical documentation, there is no clear support that the patient is at high risk to warrant screening. Therefore, fragile X mental retardation 1 laboratory testing provided on 8/09/19 was not medically necessary for the evaluation of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

a0a6304c4d1cc85414460352e88fc8c6

./data/processed/ca_cdi/summaries/20-7050.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer A 64-year-old female enrollee has requested reimbursement for CT of the thorax. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Nontuberculous mycobacterial pulmonary infection can have various radiologic manifestations. These imaging findings include tree-in-bud opacities, bronchiectasis and ground glass opacities, most commonly in the right middle lobe and lingula. These findings are often not visualized on conventional chest radiographs and are best detected on chest CT. In this case, the patients initial abnormalities were not seen on prior radiographs but were subsequently seen on chest CT. Since the patient had a recurrence of symptoms status post antibiotic treatment, the best way to visualize this recurrence would be on chest CT, as her initial findings were below the detection of radiographs. The results of the CT scan affected the patients clinical management, prompting bronchoalveolar lavage as well as additional treatment. Therefore, CT of the thorax performed on 11/09/18 was medically necessary for the evaluation of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

7b936c48f29fec2877a175cb4e86868a

./data/processed/ca_cdi/summaries/19-6674.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 1 A 60-year-old male enrollee has requested reimbursement for repair of anorectal fistula provided on 10/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees anal fistula. The physician reviewer found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Anorectal fistula are difficult, painful and not always amenable to definitive treatment. Historical treatment that involved unroofing often led to incontinence as the sphincters were divided. Setons, which are sutures placed through the tract, allow fibrosis that may reduce complications of subsequent surgery. The anal fistula plug does hold some potential advantages over mucosal advancement flap, especially in complex fistula with multiple openings. The anal fistula plug is easy to place, does not require a flap to heal in a contaminated environment, and may be associated with less pain. In addition, healing rates are equivalent in large, heterogeneous studies. However, in this case, the documentation submitted for review does not describe the location of the fistula or description of previous repair attempts. In sum, there is limited documentation supporting the anorectal fistula provided on 10/23/15 as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

79f0b7eb9f8aaf978b9844ff98693d8a

./data/processed/ca_cdi/summaries/16-4651.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 60-year-old male enrollee has requested reimbursement for repair of anorectal fistula provided on 10/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees anal fistula. The physician reviewer found that the repair of anorectal fistula provided on 10/23/15 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue. The study by Stamos and colleagues study assessed outcomes after implantation of a synthetic bioabsorbable anal fistula plug. The authors concluded Implantation of a synthetic bioabsorbable fistula plug is a reasonably efficacious treatment for complex transsphincteric anal fistulas, especially given the simplicity and low morbidity of the procedure. The use of AFP is the best option to avoid significant anal sphincter muscle damage, and resultant fecal incontinence in this clinical setting. Therefore, AFP was the superior surgical approach for treatment of the fistula without causing significant anal sphincter damage and fecal incontinence. Accordingly, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

79f0b7eb9f8aaf978b9844ff98693d8a

./data/processed/ca_cdi/summaries/16-4651.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 60-year-old male enrollee has requested reimbursement for repair of anorectal fistula provided on 10/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees anal fistula. The physician reviewer found that the American Society of Colon and Rectal Surgeons (ASCRS) has published practice parameters for the management of perianal abscess and fistula-in-ano (Steele, et al). The treatment recommendations for complex fistulas include seton, fistulotomy, fibrin glue, plug, endorectal advancement flap, and ligation of intersphincteric fistula tract. Placement of a seton with or without fistulotomy has a strong recommendation based on moderate evidence. The use of the Gore Bio-A fistula plug has been recently evaluated in recent studies. In the prospective study by Herold and colleagues, 60 patients with transsphincteric fistulas underwent plug placement and the healing rate at one year was 52%. Most importantly, there was no effect on incontinence which can be a side effect of other procedures performed for management of anal fistula such as cutting seton, fistulotomy, or endorectal advancement flap. In the study by Stamos and colleagues, 93 patients with transsphincteric fistulas were treated at 11 colon and rectal centers. The healing rates at six and 12 months were 41% and 49%, respectively. The authors concluded that implantation of a fistula plug is reasonably efficacious treatment for anal fistula, especially given its simplicity and low morbidity. Given that the support in the peer-reviewed literature and ASCRS practice parameters, the anorectal fistula provided on 10/23/15 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

79f0b7eb9f8aaf978b9844ff98693d8a

./data/processed/ca_cdi/summaries/16-4651.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 1 A 62-year-old male enrollee has requested reimbursement for laboratory testing (Fibrotest-Actitest) performed on 8/14/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting. Fibrotest and Actitest permit the noninvasive evaluation of patients with hepatitis C or hepatitis B for the presence of liver fibrosis and liver inflammation, respectively. Fibrotest and Actitest scores, on a scale of 0.0 to 1.0, are assigned a Metavir scale indicating the level of fibrosis or inflammation present. Several prospective studies have confirmed the overall accuracy of the Fibrotest in discriminating advanced from non-advanced fibrosis. All told, laboratory testing performed on 8/14/15 was likely to have been superior over other methods of evaluation. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

b87ce8f330ed3ddf584aee82a132ad6b

./data/processed/ca_cdi/summaries/16-4293.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 62-year-old male enrollee has requested reimbursement for laboratory testing (Fibrotest-Actitest) performed on 8/14/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting. It is standard of care in contemporary gastroenterology to use when possible noninvasive testing as a measure of hepatic fibrosis. Elastography is one such noninvasive technique whereby ultrasound imaging provides objective data to evaluate tissue elasticity or stiffness by measuring tissue displacement. When liver biopsy is undesired, FibroScan demonstrates greater accuracy, sensitivity, and specificity for predicting and discriminating minimal or no fibrosis from extensive fibrosis. FibroSure is more widely available than FibroScan, and represents a well-recognized community-standard approach to noninvasive assessment of hepatic fibrosis. In this patients case, the current medical evidence supports the services at issue. Thus, laboratory testing (Fibrotest-Actitest) performed on 8/14/15 was likely to have been more efficacious than other methods of evaluation. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

b87ce8f330ed3ddf584aee82a132ad6b

./data/processed/ca_cdi/summaries/16-4293.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 62-year-old male enrollee has requested reimbursement for laboratory testing (Fibrotest-Actitest) performed on 8/14/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the Fibrotest-Actitest is a serum blood test to characterize fibrosis and determine whether cirrhosis is present. With liver biopsy as the gold standard, Fibrotest has been found to perform well enough to be an effective alternative to biopsy in patients with chronic hepatitis B. Accordingly, published studies have concluded that Fibrotest-Actitest is an effective alternative to liver biopsy. In this patient with established cirrhosis, and prior liver biopsy, Fibrotest-Actitest provided a noninvasive alternative to repeating liver biopsy. For these reasons, laboratory testing performed on 8/14/15 was likely to have been of greater benefit than other methods of evaluation. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

b87ce8f330ed3ddf584aee82a132ad6b

./data/processed/ca_cdi/summaries/16-4293.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 1 A 64-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/1/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings to radiologists interpreting mammograms especially in patients with extremely or heterogeneously dense tissue such as the patient in this case. Tomosynthesis allows radiologists to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional imaging protocol was likely of greater benefit to this patient than had her exam been done with 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

9e11f5b1173126cbdc5e8afef467d604

./data/processed/ca_cdi/summaries/16-4551.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 64-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/1/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the breast tomosynthesis performed on 2/1/16 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two-dimensional (2D) and three-dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the medical literature cited above, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

9e11f5b1173126cbdc5e8afef467d604

./data/processed/ca_cdi/summaries/16-4551.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 64-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/1/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patients 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. Therefore, the breast tomosynthesis performed on 2/1/16 were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

9e11f5b1173126cbdc5e8afef467d604

./data/processed/ca_cdi/summaries/16-4551.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 1 A 50-year-old male enrollee has requested reimbursement for BCR/ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has a grade I meningioma. Magnetic resonance imaging (MRI) showed a question of slow growth versus tumor progression. There is no rationale for molecular profiling or BCR-ABL testing in this patient. Molecular profiling is used to determine treatment options in certain malignancies, but not grade I meningiomas. BCR-ABL is used in the detection and monitoring of chronic myelogenous leukemia, acute myeloid leukemia and acute lymphoblastic leukemia. In rare cases, BCR-ABL1 has been described in essential thrombocytosis, myelodysplastic syndrome, multiple myeloma (plasma cell myeloma), and malignant lymphoma. Therefore, BCR-ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18 were not likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

0e3abe44a17b08dbacb74166fc35a45d

./data/processed/ca_cdi/summaries/19-6890.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 50-year-old male enrollee has requested reimbursement for BCR/ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that testing for BCR-ABL is a gene mutation particularly prominent in chronic myelogenous leukemia, for which there is a specific targeted treatment (imatinib). There has been interest in using this drug in meningioma, although the results have been equivocal at best. There is a lack of convincing data that imatinib, regardless of mutational status, is clinically beneficial in meningioma. The Tempus XT gene panel is one of many multigene panels theoretically designed to identify a gene target for therapy. Thus far, the use of such panels appears to be rarely beneficial overall. In sum, BCR-ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18 were not likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

0e3abe44a17b08dbacb74166fc35a45d

./data/processed/ca_cdi/summaries/19-6890.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 50-year-old male enrollee has requested reimbursement for BCR/ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that a patient may exhibit resistance to therapy, and mutational analysis may be needed. This is particularly important for those that have progressed on standard regimens. The medical evidence supports clinical trials for such patients and considers such referrals standard care. Von Hoff and colleagues performed a study of 86 patients. The progression-free survival on the regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. The Tempus XT gene panel is a mutational analysis of tissue which includes IDH1/2, BCR-ABL1, BRAF, CEBPA and microsatellite instability test. This patient had mutational analysis performed on his meningioma, and some targeted regimens were recommended based on this tumor mutational analysis. The results from molecular profiling may offer a rational selection of the next regimen. Thus, BCR-ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18 were likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

0e3abe44a17b08dbacb74166fc35a45d

./data/processed/ca_cdi/summaries/19-6890.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 1 A 40-year-old female enrollee has requested reimbursement for testing for inherited thrombophilic disorders performed on 10/19/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient has a history of recurrent pregnancy loss and has tested positive for MTHFR mutation. Although this is cited by her provider as a risk factor for pregnancy loss, based on the current literature, it is unclear if MTHFR polymorphisms independently increase the risk of pregnancy loss. Diagnostic testing, including an immunology and thrombophilia work-up, is recommended for recurrent pregnancy loss. However, the minimum immunology work-up for women with recurrent pregnancy loss is measurement of anticardiolipin antibody (IgG and IgM) and lupus anticoagulant. Specifically in regards to thrombophilia testing, there is contradictory literature on the association between maternal inherited thrombophilia and recurrent spontaneous abortion occurring in the first trimester. Evaluation for an inherited thrombophilia can be considered in rare cases of recurrent, unexplained late fetal loss (after nine weeks of gestation) associated with evidence of placental ischemia and infarction and maternal vessel thrombosis. Based on the above information, there is a lack of clinical data to support the above work-up in this patient. Therefore, testing for inherited thrombophilic disorders performed on 10/19/19 was not likely to have been more beneficial than other available methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

3b8f00a958e5bbded008b65f355c8e0e

./data/processed/ca_cdi/summaries/20-7161.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 40-year-old female enrollee has requested reimbursement for testing for inherited thrombophilic disorders performed on 10/19/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient had two prior early miscarriages. As a result, her provider ordered multiple genetic blood tests for inherited thrombophilias. The use of these tests to evaluate women with prior miscarriages is not supported by available literature. An extensive literature review has shown a lack of association of heterozygosity of the MTHFR mutation and miscarriage. Rey and colleagues concluded, aMethylenetetrahydrofolate mutation, protein C, and antithrombin deficiencies were not significantly associated with fetal loss.a The American College of Obstetricians and Gynecologists does not recommend screening for this in non-pregnant or pregnant women. Thus, testing for inherited thrombophilic disorders performed on 10/19/19 was not likely to have been more beneficial than other available methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

3b8f00a958e5bbded008b65f355c8e0e

./data/processed/ca_cdi/summaries/20-7161.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 40-year-old female enrollee has requested reimbursement for testing for inherited thrombophilic disorders performed on 10/19/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that testing for thrombophilias after early miscarriage has not been shown to be clinically useful in the low risk population. Finding a genetic mutation in this population for MTHFR, Factor V (Leiden) or prothrombin genes would not change the clinical management of the patient currently or with a new pregnancy. Testing for these mutations has only been found to be clinically useful in a patient who has a personal history of a venous thrombotic event or a first-degree relative with gene mutation who has had a venous thrombotic event. In this case, the literature does not support testing for these mutations because there would be no change in clinical management. All told, testing for inherited thrombophilic disorders performed on 10/19/19 was not likely to have been more beneficial than other available methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

3b8f00a958e5bbded008b65f355c8e0e

./data/processed/ca_cdi/summaries/20-7161.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer The patient is a 21-year-old male who underwent esophagogastroduodenoscopy with biopsies for a history of abdominal pain, belching, and bloating. The documentation noted a history of hypothyroidism. The physician reviewer found that according to the ASA guideline for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures, such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care may be necessary in patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, ASA class III or higher, or morbid obesity. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, during endoscopic procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal during most procedures, and monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic variant. In this case, the records do not support the medical necessity of monitored anesthesia care over conscious sedation. Therefore, anesthesia services provided on 5/07/19 was not medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

2d1a41524ab13a5b0e8e637eaacc06ab

./data/processed/ca_cdi/summaries/20-7122.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 63-year-old female enrollee has requested reimbursement for advanced lipoprotein testing performed on 10/19/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. There are no widely accepted clinical studies demonstrating that treatment strategies directed at advanced lipoprotein testing parameters will improve clinical outcomes in individuals with dyslipidemias. Clinical trial data to date does not support the superiority of measurement of such parameters beyond what is known from a basic lipid panel in assessing treatment. This was also the conclusion of the American College of Cardiology/American Heart Association 2013 guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Risk in Adults. Therefore, advanced lipoprotein testing performed on 10/19/20 was not likely to have been more beneficial than other available standard methods of evaluation.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

8be926ac08f88e8f21192a7e1be91fe0

./data/processed/ca_cdi/summaries/21-7323.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 63-year-old female enrollee has requested reimbursement for advanced lipoprotein testing performed on 10/19/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the current medical evidence has not established the superior effectiveness of the services at issue. Lipoprotein particles, which carry cholesterol and triglycerides, are comprised in part of apolipoproteins. Although some have proposed that the measurement of lipoproteins or apolipoproteins may be useful in some patients, the 2010 American College of Cardiology Foundation/American Heart Association guideline for assessment of cardiovascular risk in asymptomatic adults does not recommend the use of these tests for cardiovascular risk assessment in asymptomatic adults. Therefore, advanced lipoprotein testing performed on 10/19/20 was not likely to have been more beneficial than other available standard methods of evaluation.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

8be926ac08f88e8f21192a7e1be91fe0

./data/processed/ca_cdi/summaries/21-7323.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 63-year-old female enrollee has requested reimbursement for advanced lipoprotein testing performed on 10/19/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that there is support for a portion of the services at issue. The National Lipid Association stated that lipoprotein (a) testing is reasonable to refine atherosclerotic cardiovascular disease risk in adults with the following: first-degree relatives with premature atherosclerotic cardiovascular disease risk (less than 55 years of age in men; less than 65 years of age in women); a personal history of premature atherosclerotic cardiovascular disease; primary severe hypercholesterolemia (LDL greater than or equal to 190 mg/dL) or suspected familial hypercholesterolemia. This patient does appear to meet the first of these criteria for lipoprotein (a) measurement. Thus, CPT 83695 was likely to have been more beneficial than other available standard methods of evaluating this patient. Apolipoprotein B may be a useful risk assessment tool in patients with normal LDL who have a high family risk for premature coronary artery disease. However, apolipoprotein B assays have not been fully standardized, and there is a lack of consensus on predictive or treatment value. Rosenson suggests the measurement of LDL particle concentration, or the surrogate measure of apolipoprotein B, in individuals with insulin resistance disorders who have not achieved their minimal acceptable LDL cholesterol targets. This patient does not meet these criteria for lipoprotein B measurement. Therefore, CPT codes 82172 and 83704 were not likely to have been more beneficial than other available standard methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

8be926ac08f88e8f21192a7e1be91fe0

./data/processed/ca_cdi/summaries/21-7323.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer The parent of a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center services provided from 9/19/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the residential treatment center services provided from 9/19/16 forward were and are medically necessary for treatment of the patients medical condition. The medical records show that the patient is aggressive, irritable, critical of others, agitated, rude and argues with peers and staff. There are significant gaps in his ability to modulate his behavior. On 9/22/16, the individual therapy note stated that he presented agitated, critical of others and defensive. He blamed others and was dismissive of feedback. The therapist noted that his struggle with negative self-talk exacerbates his impulsive and disrespectful behaviors. On 9/26/16 the group therapy note stated that the patient struggles with accepting feedback about his behaviors and suggestions of he could improve. The patient argues and becomes defensive, particularly with his disrespect for female staff members was addressed. On 10/2/16, the notes indicate the he continued to be agitated and argued with staff and peers. He continues to be agitated and angry, and becomes unable to be directed and aggressive. Based on the documentation submitted for review, the patient requires the structure and 24-hour setting of continued residential treatment center services in order to allow learned gains to become established prior to discharge to a lower level of care. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

0e06502c3145056fc49a84842f57d4ed

./data/processed/ca_cdi/summaries/16-4732.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 1 A 39-year-old male enrollee has requested reimbursement for Anser IFX testing provided on 4/23/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the services at issue. The medical evidence has not established whether therapy guided by following trough drug levels and drug antibodies is superior to routine good clinical care. The data available are uncontrolled and come from retrospective analyses. In general, for a patient failing therapy, there is a trend toward lower trough drug levels with or without the presence of antibody. However, many patients fail therapy with a normal drug level for a variety of reasons. All told, Anser IFX testing performed on 4/23/14 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

ad97b0e4a2a194550c9836139c533b97

./data/processed/ca_cdi/summaries/15-4255.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 39-year-old male enrollee has requested reimbursement for Anser IFX testing provided on 4/23/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.The physician reviewer found there is a lack of support for the services at issue in this clinical setting. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well-controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. In addition, there are technical factors relating to the use of different assay methods across studies. It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Therefore, Anser IFX testing performed on 4/23/14 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

ad97b0e4a2a194550c9836139c533b97

./data/processed/ca_cdi/summaries/15-4255.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 39-year-old male enrollee has requested reimbursement for Anser IFX testing provided on 4/23/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.The physician reviewer found the effectiveness of Anser IFX in the management of Crohns disease compared with conventional courses of action remains unproven in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing. Based on the clinical literature, Anser IFX testing performed on 4/23/14 was not likely to have been more effective than other modalities. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

ad97b0e4a2a194550c9836139c533b97

./data/processed/ca_cdi/summaries/15-4255.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer A 45-year-old male enrollee has requested authorization and coverage for maxillary and mandibular osteotomies with advancement. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that Maxillomandibular advancement can be an effective treatment for treatment of sleep disordered breathing based on several case series but more rigorous evaluation of the procedure is lacking (Prinsell). Current practice parameters list this procedure as an option for patients who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances, which are more often appropriate in mild and moderate OSA patients, have been considered and found ineffective or undesirable (Aurora, et al). Traditionally, mandibular advancement devices have been used for mild to moderate sleep apnea. This patients provider states that a mandibular advancement device is not likely to be effective in treating the patients sleep apnea. However, the most recent guidelines do not exclude the use of maxillomandibular advancement in severe OSA (Ramar, et al). In summary, the patient does have severe OSA and is CPAP intolerant but he has not tried a mandibular advancement device, a treatment which could result in adequate control of his sleep disordered breathing. Since there is another reasonable, non-surgical option available to him, the requested maxillary and mandibular osteotomies with advancement are not medically necessary. Based on the foregoing discussion, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

de3cb4664eda6d35c01c8d2953622206

./data/processed/ca_cdi/summaries/15-4266.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer The parent of a 15-year-old male enrollee has requested reimbursement for mental health residential treatment provided from 9/22/14 through 11/11/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. The reasons or precipitating factors for the patients admission on 9/22/14 are unclear. He was not a danger to himself or others. Per the records, he was not violent or aggressive, and he showed no self-harm urges. The patient was not on any medication, and he lived with his parents in a supportive environment. There is no comprehensive admission assessment by a physician. There is only a one paragraph intake assessment by a therapist. There is no psychosocial history, prior medical history or psychiatric history. There were no diagnoses provided. The records do not include physician notes, nursing notes, treatment plans or group notes except for the group note dated 10/13/14. The documentation is scanty at best and provided no insight as to what the patient was doing on a day to day basis, what services were rendered, or what benefit he received from these services. This is not consistent with care that would or should be given at a residential treatment center. This aside, the patient did not require 24-hour supervision in a restricted, structured setting. He could have received continued evaluation and treatment at a lower level of care. All told, mental health residential treatment provided from 9/22/14 through 11/11/14 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

73ca6c68aff72e14d6aa22c7605f6d9c

./data/processed/ca_cdi/summaries/16-4401.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 24-year-old female enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the medical records provided for review, the patient presents with a large mediastinal mass which requires radiation. The patient has an excellent long term survival, upwards of 90%, and therefore all efforts should be made to mitigate long term toxicities from radiation therapy which include heart and lung damage. IMRT can be utilized to minimize dose to the surrounding heart and lungs. Comparative planning between IMRT and three-dimensional (3D) conformal treatments were submitted for review. They reveal that the IMRT plan is able to significantly reduce radiation dose to the heart and lungs which will decrease the incidence of long term toxicities seen in these organs. The National Comprehensive Cancer Network (NCCN) guidelines state that IMRT can be used in treatment of patients with Hodgkin's disease. Furthermore, there are comparative studies which have demonstrated that IMRT reduces the radiation dose compared to older methods of delivering radiation such as 3D conformal techniques (Filippi, et al; Lu, et al). Therefore, IMRT is likely to be more beneficial for treatment of this patients Hodgkins disease 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

0e5a62f7bfce582c0f89176b5734ccf7

./data/processed/ca_cdi/summaries/16-4386.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 24-year-old female enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the Health Insurer has denied this request as investigational indicating medical studies do not show that IMRT works as well as or better than other types of treatment. There are emerging data for the use of IMRT for Hodgkins lymphoma (Chera, et al). The rationale to use IMRT includes relative sparing of the lungs, heart, salivary glands, breast and other tissues. Reducing the mean cardiac dose is particularly clinically relevant in a patient expected to have a long term survival, particularly if cardiotoxic drugs were used, such as is in this case. Hodgkin lymphoma fields have historically been much more comprehensive in terms of volume. For this patient, clinically significant reductions in dose-volume measures with IMRT are seen in the mean heart dose; left breast, and esophageal dose exposure is also reduced with IMRT. In younger patients, IMRT is used to spare breast tissue, in order to reduce subsequent breast cancer risks. In sum, IMRT is indicated for this patient and there is sufficient support provided showing a plausible, clinically meaningful benefit in this patient. Given the support above, IMRT 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

0e5a62f7bfce582c0f89176b5734ccf7

./data/processed/ca_cdi/summaries/16-4386.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 24-year-old female enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the goal for the treatment of Hodgkins disease in young adults is to eradicate the disease to minimize the risks of late effects secondary to therapy. The late effects of treatment have become more apparent with increased survival of Hodgkins patients. IMRT is superior to three-dimensional conformal radiation therapy (3D-CRT) for patients with bulky mediastinal disease. This is because IMRT allows a more conformal dose of radiation to mediastinal disease while at the same time delivering a lower dose to adjacent sensitive organs such as heart and lungs. The National Comprehensive Cancer Network (NCCN) Hodgkins lymphoma guidelines state Advanced radiation therapy (RT) technologies such as IMRT, breath hold or respiratory gating, image guided RT or proton therapy may offer significant and clinically relevant advantages in specific instances to spare important [organs at risk] OAR such as the heart (including coronary arteries, valves and left ventricles), and decrease the risk for late normal tissue damage while still achieving the primary goal of local tumor control. In this case, IMRT will be more beneficial treatment to avoid long-term complications in this young patient who has a very high chance of cure. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

0e5a62f7bfce582c0f89176b5734ccf7

./data/processed/ca_cdi/summaries/16-4386.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer A 45-year-old male enrollee has requested reimbursement for inpatient admission at a non-participating facility from 11/13/16 through 11/14/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees acute appendicitis. The physician reviewer found that the inpatient admission was not medically necessary for this patient. Inpatient care is 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 physician 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/treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this patients case, he was admitted in stable condition and could have been treated at an observational level of care. He had a laparoscopic appendectomy without any complications. This procedure does not have to be performed on an inpatient only basis. Pain control was adequate after the surgery, and the patient tolerated an oral diet. The submitted documentation demonstrates that this patient could have been treated at a lower level of care. As such, admission at a non-participating facility from 11/13/16 through 11/14/16 were not medically necessary for treatment of the patients medical condition. Therefore, for the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

6687f9fbec9c33bbea6244443e28f517

./data/processed/ca_cdi/summaries/17-6113.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 The parent of a five-year-old male enrollee has requested reimbursement for gene testing performed on 11/20/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees generalized epilepsy of unknown etiology. The physician reviewer found the clinical utility of CMA is well established in the peer-reviewed literature and is considered first-line genetic tests for individuals with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics (AAP) and the American College of Medical Genetics (ACMG) (Schaefer, et al; Moeschler, et al). Olson and colleagues evaluated the role of copy number variation (CNV) abnormalities detectable using CMA testing in patients with epilepsy. The authors found that in at least 40 cases (5%), the epilepsy phenotype was explained by a 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. Similarly, Striano and colleagues compared 279 patients with unexplained epilepsy to patients with non-syndrome intellectual disability and healthy controls using CMA. The authors found that patients with epilepsy show a significantly increased burden of large, rare, gene-rich CNVs. Several specific (ion channel) genes were noted to have a specific association between the identified CNVs and epilepsy (Striano, et al). Moreover, CMA has been shown to provide clinically actionable information with results influencing medical care by precipitating medical referrals, diagnostic imaging, and specific laboratory testing (Coulter, et al). For the reasons provided, the gene testing performed on 11/20/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

4d35d3992de5fb531aac5efbf36ec79a

./data/processed/ca_cdi/summaries/17-4918.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 The parent of a five-year-old male enrollee has requested reimbursement for gene testing performed on 11/20/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees generalized epilepsy of unknown etiology. The physician reviewer found the gene testing performed on 11/20/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. CMA has become standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies. Seven percent of microarray results impact clinical management, a rate which is similar to other genetic tests (Riggs, et al). Olson and colleagues found that at least 5% of individuals with epilepsy had pathogenic copy number variants. In sum, data have emerged showing that actionable findings from chromosomal microarray justify its use. All told, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

4d35d3992de5fb531aac5efbf36ec79a

./data/processed/ca_cdi/summaries/17-4918.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 The parent of a five-year-old male enrollee has requested reimbursement for gene testing performed on 11/20/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees generalized epilepsy of unknown etiology. The physician reviewer found that ezugha and colleagues studied 82 children with developmental delay or seizures. The study found abnormalities on CMA in 20 children (23.5%), but found the highest yield on CMA in those with four or more additional clinical variables, including seizures, hypotonia, learning delay, hypotonia, dysmorphic features, developmental delay, or autism. In children with three or fewer of these variables, like this patient who has no additional variables besides epilepsy, the yield of CMA was 8.7%. Given that this patient does not have heath concerns outside of seizures, the likelihood of abnormal finding on CMA is likely to be low. In addition, CMA is recommended as standard of care in children with intellectual or developmental disability or multiple congenital anomalies. This patient does not meet these criteria. As such, the gene testing performed on 11/20/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

4d35d3992de5fb531aac5efbf36ec79a

./data/processed/ca_cdi/summaries/17-4918.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer A 51-year-old female enrollee has requested authorization and coverage for Pazeo (olopatadine hydrochloride ophthalmic solution 0.7%) eye drops. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees eye condition The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. This patient has significant dry eye and chronic allergic conjunctivitis. Per the provider and noted by the patient, she has tried several of the over the counter medications without success or improvement of her symptoms. This patient has also been prescribed Pataday drops but those eye drops were also ineffective. The records indicate that this patient has tried and failed standard treatments. All told, Pazeo (olopatadine hydrochloride ophthalmic solution 0.7%) eye drops for treatment of this patients eye condition is medically necessary. Therefore, based on the reasons stated above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

a5e41ff31fa0363658d186b54b9d9ef7

./data/processed/ca_cdi/summaries/17-4804.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 1 A 52-year-old female enrollee has requested reimbursement for gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Berger reported on 156 cases, but there was not sufficient follow-up to determine the real value of the assay. It is not known how the five-year DecisionDx-Melanoma testing data compares to the ten-year Balch data. Most importantly, it is not clear if DecisionDx-Melanoma testing can be used to make clinical decisions about treatment. Therefore, gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18 was not likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

6fabcbfe638d67304c8be1f055471289

./data/processed/ca_cdi/summaries/20-6978.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 52-year-old female enrollee has requested reimbursement for gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has an early stage melanoma. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, 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. All told, gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18 was not likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

6fabcbfe638d67304c8be1f055471289

./data/processed/ca_cdi/summaries/20-6978.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 52-year-old female enrollee has requested reimbursement for gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the 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. Thus, gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18 was not likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

6fabcbfe638d67304c8be1f055471289

./data/processed/ca_cdi/summaries/20-6978.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer The patient is a 59-year-old male with a history of prior bilateral renal oncocytomas. The patient has requested reimbursement for cryoablation for kidney mass performed on 11/06/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. The patient had a renal tumor (oncocytomas) that was a stage T1 lesion. The patient declined active surveillance. The patient was not an appropriate surgical candidate for nephrectomy or partial nephrectomy, given the history of recurrent oncocytomas. The tumor was not an angiomyolipoma. Radiofrequency cryoablation of the renal tumor is supported in this clinical scenario. The medical literature has demonstrated renal cryoablation to have similar or improved outcomes compared with nephrectomy. The studies consistently showed a lower decline in glomerular filtration rate with renal cryoablation. Therefore, cryoablation of the renal mass on 11/06/20 was medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

5fc9d9c3ebd53157a30acae8900bd343

./data/processed/ca_cdi/summaries/21-7335.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer The patient is a 59-year-old female who was admitted to residential treatment for worsening depressive symptoms on 1/05/20. At the time, she endorsed low mood as well as many neurovegetative impairments, including increased sleep, decreased energy and anhedonia. The physician reviewer found that based on the limited information noted above, the patient does not meet medical necessity criteria for residential treatment. There is no evidence of suicidality. There is no evidence of functional decline. There was no evidence of psychosis or disorganization. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. In terms of risk of harm, the records support a score of 2. She had a low risk of harm given lack of suicidality or self-injurious behaviors. With regard to functional status, the records support a score of 3. The patient reported that she had not had employment for over a year. In terms of comorbidity, the records support a score of 4. She has major medical comorbidity, including history of head trauma/closed head injury as well as stage IV vaginal cancer. With regard to level of stress of the recovery environment, the records support a score of 2. Her recovery environment is minimally stressful based on the information provided. She reported a close relationship with her daughter. In terms of level of support of the recovery environment, the records support a score of 2. The documentation noted that the patient had a psychiatrist and therapist. With regard to resilience and treatment history, the records support a score of 3. She has seen may providers, without complete remission of her symptoms. In terms of engagement and recovery, the records support a score of 2. The patient has been adherent with treatment plan, including medication. Thus, her composite score is 18. Based on LOCUS criteria, she did not meet criteria for residential treatment level of care. Therefore, residential treatment provided from 1/05/20 through 1/09/20 was not medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

5266db1de1a7f34bad3a9e818903ce3e

./data/processed/ca_cdi/summaries/20-7209.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 55-year-old male enrollee has requested reimbursement for CPT code 81479 provided on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there currently are three major approaches to the management of localized prostate cancer. These include surgical prostatectomy, radiation therapy, or active surveillance with no specific treatment given. Recommendations as to these options are based on risk stratification, which is a process that takes into account patient factors, prostate-specific antigen level, clinical stage, Gleason grade, and the percent of involvement of the cores. Using this methodology, this patient falls into the very low risk category. Generally, active surveillance is recommended for such patients. Oncotype DX testing is an analysis of the expression of 12 genes in an individuals cancer cells. It then classifies that cancer into various risk categories of cancer progression. Such analyses appear useful in patients undergoing prostatectomy and in other risk categories. However, there is a lack of support for the use of this testing in patients in the very low risk category, such as this patient. Therefore, CPT code 81479 provided on 12/21/18 was not likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

2ed802746df3002536ad4859b4de33f2

./data/processed/ca_cdi/summaries/20-6958.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 55-year-old male enrollee has requested reimbursement for CPT code 81479 provided on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. This patient with low risk disease meets criteria for testing. In sum, CPT code 81479 provided on 12/21/18 was likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

2ed802746df3002536ad4859b4de33f2

./data/processed/ca_cdi/summaries/20-6958.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 55-year-old male enrollee has requested reimbursement for CPT code 81479 provided on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features, such as the grade of tumor and prostate-specific antigen level. This helps guide the most appropriate therapy for patients, taking into account their age and comorbidities, because many patients will not require therapy (i.e. surgery or radiation) and may be followed closely instead. The important features to recognize are Gleason score and prostate-specific antigen level, but these are imperfect. Thus, current biomarkers are inadequate for risk stratification, and better prognostic biomarkers are needed. The Oncotype DX is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). The GPS may help identify patients with very low risk disease that can be followed rather than referred for surgery. The medical evidence supports the services at issue in this clinical setting. Thus, CPT code 81479 provided on 12/21/18 was likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

2ed802746df3002536ad4859b4de33f2

./data/processed/ca_cdi/summaries/20-6958.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer A 35-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 hepatitis C virus. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for treating hepatitis C, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Moreover, the combination of ledipasvir/sofosbuvir Harvoni is recommended for hepatitis C genotype 4 patients based upon trial studies (Kapoor, et al; Abergel, et al). Abergel and colleagues reported data from an open-label single-arm study including 22 HCV genotype 4 infected, treatment-naive patients (only 1 with cirrhosis) with an SVR rate of 95% (21/22) at 12 weeks. Therefore, the request for Harvoni is medically necessary for treatment of the patients HCV genotype 4 infection. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

7a3ccac050c9011fc956101217a00ff8

./data/processed/ca_cdi/summaries/15-4208.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 1 A 67-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees bilateral sacroiliac joint pain status post revision lumbar surgery. The physician reviewer found that according to the coverage criteria by the International Society for the Advancement of Spine Surgery (ISASS), the criteria for sacroiliac joint fusion have not been met in this patients case. The patients records do not include documentation of 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; or sacroiliac joint steroid injection must be reported. Moreover, there must be evidence that additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been ruled out. Thus, although the patient has demonstrated continued pain that interferes with activities of daily living and results in functional disability, the patient has not adequately satisfied all of the ISASS criteria. All told, the requested sacroiliac 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 service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

398079811e51600478c3530e819717ff

./data/processed/ca_cdi/summaries/18-6166.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 67-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees bilateral sacroiliac joint pain status post revision lumbar surgery. The physician reviewer found that the medical records indicate that the patient has had previous lumbar fusion surgery. Currently, there is a lack of documentation of sacroiliac joint instability, fracture, or tumor. For this reason, the criteria for sacroiliac joint fusion have not been met. Further, long-term outcomes and complications are not well-defined for use in this clinical setting. Given these findings, the requested sacroiliac joint fusion is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

398079811e51600478c3530e819717ff

./data/processed/ca_cdi/summaries/18-6166.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 67-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees bilateral sacroiliac joint pain status post revision lumbar surgery. The physician reviewer found that this patient presents with persistent severe left greater than right SI joint pain. Functional difficulty was documented with activities of daily living and ambulation. He is status post multiple lumbar fusion surgeries resulting in L3-4, L4-5 and L5-S1 interbody fusion with posterior instrumentation from L3 to S1. He has reported progressively worsening bilateral SI joint pain following the last surgery on 11/1/16. There is evidence of long-term conservative treatment including medications, cane/walker use, bracing, activity modification, SI joint injections, home exercise program, and physical therapy without sustained improvement. Clinical examination findings have documented SI joint tenderness with three positive SI provocative tests. In addition, there is radiographic evidence of SI joint sacroiliitis. Moreover, bilateral SI joint injections have been documented with 90-100% temporary pain relief. Current evidence based medical guideline and peer-reviewed surgical indications for SI joint fusion have therefore been met. Accordingly, the requested 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 service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

398079811e51600478c3530e819717ff

./data/processed/ca_cdi/summaries/18-6166.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer A 62-year-old female enrollee has requested reimbursement for hospital services provided on 2/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees dislocated thumb. The physician reviewer found the inpatient admission was not medically necessary in this patients case. Inpatient care is necessary when the patients signs, 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. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. The documentation provided did not support acute exacerbations of chronic medical problems. The records indicated that the patients pain was controlled. She could have been treated at a lower level of care for the procedure. Per InterQual criteria for acute inpatient admission, the criteria was not met? in this patients case. As such, the hospital services provided on 2/6/17 were not medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

5d3769550a073bb480a1524bc1e27f22

./data/processed/ca_cdi/summaries/18-6155.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 The parent of an 11-year-old male enrollee has requested reimbursement for the Prometheus Anser IFX test performed on 7/16/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that on the current peer-reviewed medical literature, the Anser IFX test is used as part of standard of therapy in patients who treated with infliximab to determine whether a patient is benefiting from the drug or if they need an increased dose. The information received from this test may lead to a shortened interval or increased dose or possibly change of medication. The Anser IFX test helps to inform the provider whether the serum levels of drug are in the range to be beneficial and effective or if a patient has antibodies that could potentially lead to a reaction, failure to respond. This can help guide the provider in dosing or may lead them to discontinue the drug if the patient is not likely to benefit from the medication. This can not only prevent the patient from having a flare but save them from potential side effects of a drug they may not benefit from. In this case, the patient was on infliximab but started having rectal bleeding. Thus, the Anser IFX testing performed on 7/16/14 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

06142c8f711fa81248f48daabf7350b7

./data/processed/ca_cdi/summaries/16-4751.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 The parent of an 11-year-old male enrollee has requested reimbursement for the Prometheus Anser IFX test performed on 7/16/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found current studies indicate that measurement of infliximab levels and anti-infliximab antibodies produces actionable data (Afif, et al; Yanai and Hanauer). Change of dose or medication based on these results improves response to treatment, as measured by clinical response. Minar and colleagues reported that among 60 pediatric Crohns patients with secondary loss of response, a total of 23 patients had subtherapeutic infliximab levels and 11 had antibodies to infliximab. Overall, 29 patients had a change of treatment prompted by the results of drug monitoring. This group had a rate of clinical remission at six months similar to those whose treatment was considered appropriate based on drug monitoring results. Among the subgroup of patients whose treatment change was an intensification of infliximab dosing, remission rate increased from 16% at baseline to 72% at six months. Hoekman and colleagues demonstrated that lower infliximab trough levels is associated with elevated markers of mucosal inflammation in children. Given this support, the Anser IFX testing performed on 7/16/14 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.]

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

06142c8f711fa81248f48daabf7350b7

./data/processed/ca_cdi/summaries/16-4751.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 The parent of an 11-year-old male enrollee has requested reimbursement for the Prometheus Anser IFX test performed on 7/16/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that in the current peer-reviewed medical literature, Yanai and Hanauer concluded that although the incorporation of the measurement of trough levels and anti-drug antibodies may be helpful in this clinical setting, prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response. The testing for trough IFX levels and antibodies are appropriate and within the accepted standard of practice now in patients treated with IFX. The Anser IFX testing in this patients case was non-trough. All told, the mid treatment Anser IFX lab test performed on 7/16/14 was not likely to be more beneficial for evaluation of this patients ulcerative colitis than any available standard testing. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

06142c8f711fa81248f48daabf7350b7

./data/processed/ca_cdi/summaries/16-4751.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer The patient is a 35-year-old male who was admitted on 9/17/18. The records noted acute psychosis due to auditory hallucinations, disorganized behavior, and homicidal threats toward his parents, whom he was living with. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. With regard to risk of harm, the records support a score of 5 due to homicidal ideation, auditory hallucinations, paranoia and delusions. His ability to decompensate due to noncompliance remained high. In terms of functional status, the records support a score of 5 due to inability to provide for basic needs due to his symptoms. His comorbidity dimension was scored a 2. He had severe mental illness. Due to lack of cooperation with medical staff, other medical conditions were difficult to determine. In terms of level of stress of the recovery environment, the records support a score of 4 due to lack of employment, housing, and inability to manage his day-to-day life. With regard to level of support of the recovery environment, the records support a score of a 3. The records noted involvement of parents and other agencies to help him, but a lack of connection to friends or employers. In terms of treatment history, the records support a score of 4 due to multiple hospitalizations, multiple treatments that failed due to noncompliance due to symptoms of schizophrenia. With regard to engagement, the records support a score of 5 due to refusal to take vital signs, take blood draws, and refusal to participate in group and individual therapy. Therefore, the records support a score of 28. The records support inpatient hospitalization in the patients case. Thus, inpatient behavioral health services provided from 10/01/18 through 11/12/18 were medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

161bdba00953e580a0224f4d40e18eb8

./data/processed/ca_cdi/summaries/20-7009.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer The patient is a 46-year-old female who has requested reimbursement for laboratory testing (81219 and 81403) provided on 6/29/20. The patient has requested reimbursement for laboratory testing (81219 and 81403) provided on 6/29/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the patients medical condition. This denial is the subject of this appeal and determination. The physician reviewer found that myeloproliferative disorders, such as essential thrombocytosis, polycythemia vera, and primary myelofibrosis, are suspected when a patient has persistent leukocytosis and thrombocytosis. Usually, platelets are persistently elevated above 500, white blood cell count is above 30 and some abnormal appearing white blood cells are usually seen. On 6/29/20, this patient had a normal white blood cell count and platelets, and a peripheral smear was described as normal. Based on these findings, a myeloproliferative disorder would be of low suspicion and further confirmatory tests such as JAK2 V617F cascading reflex to CALR, JAK2 exon 12, MPL, and CSF3R would not be indicated. There is a lack of support for the services at issue in this clinical setting. Therefore, laboratory testing (81219 and 81403) provided on 6/29/20 was not medically necessary for the evaluation of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

83a80637c48296b09ef07c99d4408814

./data/processed/ca_cdi/summaries/21-7295.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer A 60-year-old female enrollee has requested reimbursement for the emergency department services provided at Hoag Hospital on 12/1/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patients symptoms on 12/1/16 did meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his or her health. The patient was directed to go to the emergency department by her primary care provider to rule out diverticulitis. She was evaluated and found to have diverticulitis, was offered admission, and declined. She was prescribed oral antibiotics. The medical records support a comprehensive history and medical decision making of high complexity to support CPT code 99285. The patient then left and went to the second emergency department. There she received one dose of intravenous antibiotics and was discharged. All told, the emergency department services provided at Hoag Hospital on 12/1/16 were required on an emergent basis and include comprehensive history and medical decision making of high complexity to support CPT code 99285. Therefore, the Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

7aa36ce965570dc66736a4f7040ca872

./data/processed/ca_cdi/summaries/17-6060.jsonl

Insurer Denial Overturned

Medical Necessity