Answer: The patients parent has requested authorization and coverage for brand medication, Norditropin FlexPro.

Answer: This patients growth chart and clinical records support that this patient initially met FDA approved criteria for treatment with GH therapy due to idiopathic short stature with height z-score below -2.25 SDs from about age seven to age nine, despite treatment with somatotropin during some of this timeframe. Absent true puberty, this patients height z-score eventually improved significantly into the normal range while receiving somatotropin therapy, a clinical response displayed by a minority of prepubertal patients with idiopathic short stature. Her recent predicted adult height remains more than 2 SDs below the mean for North American women. Her growth pattern and bone ages have been consistent with her familial pattern of growth and development and consistent with both benign premature adrenarche and familial idiopathic short stature.

Context: Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for brand medication, Norditropin FlexPro. The U.S. Food and Drug Administration (FDA) has approved GH therapy for patients with idiopathic short stature. This patients growth chart and clinical records support that this patient initially met FDA approved criteria for treatment with GH therapy due to idiopathic short stature with height z-score below -2.25 SDs from about age seven to age nine, despite treatment with somatotropin during some of this timeframe. Absent true puberty, this patients height z-score eventually improved significantly into the normal range while receiving somatotropin therapy, a clinical response displayed by a minority of prepubertal patients with idiopathic short stature. Her recent predicted adult height remains more than 2 SDs below the mean for North American women. Her growth pattern and bone ages have been consistent with her familial pattern of growth and development and consistent with both benign premature adrenarche and familial idiopathic short stature. Somatotropin therapy is indicated to help the patient attain a final adult height z-score above -2 SDs for North American women. However, this patients records lack documentation to meet the criteria for treatment with GH therapy. Specifically, there is no record of karyotype testing to exclude mosaic Turner syndrome, or brain MRI with and without gadolinium contrast obtained either before or after initiation of somatotropin. In the absence of this data, the requested Brand medication, Norditropin FlexPro is not medically necessary for this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer board certified in pediatrics with subspecialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The patients parent has requested authorization and coverage for residential treatment center (RTC) services.

Answer: The patient had a moderately stressful environment due to the recent death of his grandmother, and his fathers illness and homelessness.

Answer: The patient had poor resiliency and/or response to treatment, as he overdosed while participating in a partial hospitalization program (PHP), and his symptoms of depression, anxiety, and cravings continued in residential treatment.

Answer: The patient was motived and participated in treatment.

Answer: The patient had significant comorbidity, due to the presence of substance abuse, hallucinations, and a history of pancreatitis.

Answer: The documentation noted moderate functional impairment due to conflict with parents and social isolation due to substance use. The patient demonstrated recent gains or stabilization in functioning while participating in treatment in a structured, protected, and/or enriched service.

Answer: The patient has a serious risk of harm, due to substance abuse, including a recent overdose requiring hospitalization.

Context: Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm, due to substance abuse, including a recent overdose requiring hospitalization. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflict with parents and social isolation due to substance use. The patient demonstrated recent gains or stabilization in functioning while participating in treatment in a structured, protected, and/or enriched service. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse, hallucinations, and a history of pancreatitis. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to the recent death of his grandmother, and his fathers illness and homelessness. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents participation in treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, as he overdosed while participating in a partial hospitalization program (PHP), and his symptoms of depression, anxiety, and cravings continued in residential treatment.With regard to treatment acceptance and engagement, the records support a score of 2. The patient was motived and participated in treatment.Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored residence-based services, due to the serious risk of harm score of 4. This is consistent with the RTC level of care. Therefore, RTC services are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: An enrollee has requested authorization and coverage for a short-stem resurfacing procedure for the right shoulder

Answer: In this case, the patient presents with complaints of bilateral shoulder pain, right greater than left, and decreased range of motion. The patients functional limitations are noted in activities of daily living. Her clinical exam findings are reported consistent with imaging evidence of severe glenohumeral osteoarthritis with effusion, moderate tendinopathy of the long head of the biceps tendon, moderate-severe acromioclavicular joint arthrosis, and rotator cuff tendinopathy with at least partial-thickness tearing of the supraspinatus. There is radiographic evidence of bone-on-bone glenohumeral osteoarthritis. The patient has requested authorization for a resurfacing procedure of the right shoulder.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a short-stem resurfacing procedure for the right shoulder.Researchers indicate that the potential advantages of humeral resurfacing, as compared with conventional shoulder arthroplasty, are: (1) no osteotomy is performed (and thus the head-shaft angle does not have to be addressed); (2) minimal bone resection; (3) a short operative time; (4) a low prevalence of humeral periprosthetic fractures; and (5) ease of revision to a conventional total shoulder replacement, if needed. Outcomes of surface replacement arthroplasty have been comparable with those of arthroplasties with a stemmed prosthesis in numerous short and mid-term follow-up studies. Future studies are required to assess the long-term outcomes of humeral resurfacing and to evaluate alternative surface bearing materials, especially on the glenoid side. Resurfacing appears to be a viable option for shoulder replacement, especially in young patients. Medical literature concluded that the indications for glenoid resurfacing are controversial. Advantages of glenoid resurfacing include decreased glenoid pain from metal-on-bone articulation, increased stability provided by the conforming glenoid component in the presence of asymmetric glenoid wear, and lateralization of the joint line providing for improved range of motion and strength. Patients with severe rotator cuff disease, persistent instability, and lack of glenoid bone stock should be treated with hemiarthroplasty alone because glenoid resurfacing is associated with early loosening and failure.In this case, the patient presents with complaints of bilateral shoulder pain, right greater than left, and decreased range of motion. The patients functional limitations are noted in activities of daily living. Her clinical exam findings are reported consistent with imaging evidence of severe glenohumeral osteoarthritis with effusion, moderate tendinopathy of the long head of the biceps tendon, moderate-severe acromioclavicular joint arthrosis, and rotator cuff tendinopathy with at least partial-thickness tearing of the supraspinatus. There is radiographic evidence of bone-on-bone glenohumeral osteoarthritis. The patient has requested authorization for a resurfacing procedure of the right shoulder. Current evidence based medical literature indicates that resurfacing appeared to be a viable option for shoulder replacement, especially in younger patients. Glenoid resurfacing is associated with early loosening and failure in patients with severe rotator cuff disease, persistent instability, and lack of glenoid bone stock. In this case, there is no consensus between the physicians on the surgical treatment plan. However, the active patients age, deficient rotator cuff, shoulder osteoarthritis, knowledge and positive experience with resurfacing supports the requested procedure. The short stem resurfacing procedure represents a reasonable alternative to ongoing non-operative and more invasive shoulder replacement. Therefore, a short-stem resurfacing procedure for the right shoulder is medically necessary for treatment of the patients medical condition (right shoulder osteoarthritis and tears in the rotator cuff).Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The patient has requested authorization and coverage for continued hospitalization until her course of antibiotics is complete for her infection, and her heart rate is stabilized. The records provided for review document a history of glioblastoma multiforme, stroke, seizures, and sinus tachycardia. The patient has been diagnosed with a urinary tract infection (UTI) and she is currently on antibiotics.

Context: The patient has requested authorization and coverage for continued hospitalization until her course of antibiotics is complete for her infection, and her heart rate is stabilized. The records provided for review document a history of glioblastoma multiforme, stroke, seizures, and sinus tachycardia. The patient has been diagnosed with a urinary tract infection (UTI) and she is currently on antibiotics. There is a lack of clinical indication for the patient to remain admitted to the hospital in order to complete her antibiotic dosing. Such medications can be safely administered in a long-term care setting such a skilled nursing facility or another long-term care facility. Moreover, prolonged hospitalization increases this immunocompromised patients risk to other infections. As such, an infection such as a UTI is treated without inpatient care in an outpatient setting when possible. For these reasons, the requested continued hospitalization until her course of antibiotics is complete for her infection and her heart rate is stabilized is not medically necessary for treatment of this patient.

Question: What is the background context in this case summary?


Answer: The parent of the patient has requested authorization and coverage for speech therapy services.

Answer: In this case, although the patients progress is slow, he continues to make progress. His providers recommend that speech therapy be continued.

Context: Nature of Statutory Criteria/Case Summary: The parent of the patient has requested authorization and coverage for speech therapy services. The submitted documentation supports the medical necessity of the requested services. Speech therapy is standard of care for children with autism spectrum disorder. Hyman and colleagues stated, All children with autism spectrum disorder (ASD) should have documentation of specific coexisting speech and language diagnoses so that appropriate intervention might be provided. Speech-language therapy is the most commonly identified intervention provided for children with ASD. Researchers noted the importance of early intervention for children with autism spectrum disorder. Studies concluded that behavioral interventions were evidence based to induce speech among individuals with developmental disabilities. Scientists described treatment for autism spectrum disorder involving intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. In this case, although the patients progress is slow, he continues to make progress. His providers recommend that speech therapy be continued. Therefore, speech therapy services are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The patient has requested reimbursement for Wide local excision of melanoma in situ.

Answer: The records provided for review document that this patient presented to his provider with a diagnosis of melanoma in situ on the cheek, which required excision.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Wide local excision of melanoma in situ.  Per Health and Safety Code section 1345(h), health plans are required to cover urgent care services. Per that same provision, urgent care services are defined as, services to prevent serious deterioration of the enrollees health resulting from unforeseen illness or injury. The records provided for review document that this patient presented to his provider with a diagnosis of melanoma in situ on the cheek, which required excision. Based on the definition of urgent care services, the patients melanoma did not require urgent excision on the date of service. The American Academy of Dermatology (AAD) guidelines on the management of melanoma recommend definitive excision within two months of diagnosis. Moreover, current data suggest that there is a paucity of evidence to suggest that a shorter timeline for removal of the tumor changes long-term patient health outcomes. Based on these findings, the procedure could have been performed within the two-month timeframe without urgent excision on the date of service. A wide local excision by a plastic surgeon or dermatologist was reasonable. There was no reasonable expectation of deterioration in the patients health to support an urgent indication for the procedure. Therefore, the wide local excision of melanoma in situ was not provided for treatment of an urgent medical condition as defined by California law. Final Result: The reviewer determined that the wide local excision of melanoma in situ was not provided for treatment of an urgent medical condition as defined by California law. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: An enrollee has requested authorization and coverage for laparoscopic radiofrequency ablation of fibroids. This patient has heavy bleeding, pelvic pain, and bulk symptoms. Ultrasound demonstrated that the patients fibroids are intramural and less than 6 cm.

Context: An enrollee has requested authorization and coverage for laparoscopic radiofrequency ablation of fibroids. This patient has heavy bleeding, pelvic pain, and bulk symptoms. Ultrasound demonstrated that the patients fibroids are intramural and less than 6 cm. Standard options for treatment include hysterectomy, myomectomy, and uterine artery embolization. Radiofrequency ablation procedure is a less invasive alternative treatment for myomas of appropriate size and location. Researchers found that radiofrequency ablation of uterine fibroids reduces fibroid volume, provides significant durable improvements in fibroid-related quality of life, and is associated with favorable reintervention rates. Based on the peer-reviewed medical literature, the requested laparoscopic radiofrequency ablation of fibroids is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The patient has requested authorization and coverage for ivabradine (Corlanor). Based on the records provided for review, this patient has a history of postural orthostatic tachycardia syndrome (POTS) and she is being treated with low dose carvedilol

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ivabradine (Corlanor). Based on the records provided for review, this patient has a history of postural orthostatic tachycardia syndrome (POTS) and she is being treated with low dose carvedilol without any documented trial or intolerance to higher dose beta-blocker therapy. A recent clinic note did not document any tachycardia or hypotension, at baseline or after standing, despite symptom occurrence. Studies evaluating Corlanor for the treatment of patients with POTS have demonstrated lower heart rate and reduced symptoms in some patients. However, the available studies are small and without comparison control groups. The patient has not reported any tachycardia during symptoms while on low dose carvedilol and there is no documented contraindication to higher dose carvedilol therapy. For these reasons, the requested ivabradine (Corlanor) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The parent of an enrollee has requested reimbursement and authorization and coverage for Visual Communication Analysis with Self-Determination Theory (SDT) services (five days per week, 2.5 hours per day), and Visual Communication Analysis with Self-Determination Theory (SDT) Supervision services (three hours per week).In this case, there are

Answer: reports from the patient's parents and Visual Communication Analysis therapist that the patient's maladaptive behaviors have decreased, and his ability to identify letters has increased during the time that he has received Visual Communication Analysis.

Context: Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for Visual Communication Analysis with Self-Determination Theory (SDT) services (five days per week, 2.5 hours per day), and Visual Communication Analysis with Self-Determination Theory (SDT) Supervision services (three hours per week).In this case, there are anecdotal reports from the patient's parents and Visual Communication Analysis therapist that the patient's maladaptive behaviors have decreased, and his ability to identify letters has increased during the time that he has received Visual Communication Analysis. No plan for parent training is provided. Under these circumstances, the submitted documentation does not support that Visual Communication Analysis and Self-Determination Theory are medically necessary for the patient. Therefore, Visual Communication Analysis with Self-Determination Theory (SDT) services (five days per week, 2.5 hours per day) and Visual Communication Analysis with Self-Determination Theory (SDT) Supervision services (three hours per week) were not, and are not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The patients parent has requested reimbursement for intensive outpatient program (IOP) psychiatric services.

Context: The patients parent has requested reimbursement for intensive outpatient program (IOP) psychiatric services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, 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) developmental, medical, substance use 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. The patients composite score is consistent with high intensity community based services. This level of care is consistent with the IOP level of care. Given these findings, the IOP psychiatric services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The patient has requested reimbursement for Euflexxa injections in both knees.

Answer: In this case, the patient has a history of significant benefit from prior viscosupplementation injections.

Answer: The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties.

Context: The patient has requested reimbursement for Euflexxa injections in both knees. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history of significant benefit from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. The medical evidence supports the services at issue in this clinical setting. Therefore, Euflexxa injections in both knees were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The enrollees representative is requesting reimbursement and authorization and coverage for residential treatment center services. The enrollee has diagnoses of moderate recurrent major depressive disorder, combined presentation attention deficit hyperactivity disorder, intermittent explosive disorder, nicotine dependence, cannabis use disorder, and alcohol abuse.

Answer: he has no active suicidal or homicidal ideation, but he displays extreme distress and there is a history of suicidal/homicidal behavior.

Answer: the enrollee demonstrates significant improvement in function following a period of deterioration.

Answer: the family/primary caretakers are willing and able to participate in treatment if requested to do so and have the capacity to effect needed changes.

Answer: previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. Also, developmental pressures and life changes have caused some deterioration in function.

Answer: the enrollee has developed a positive therapeutic relationship with clinicians and other primary care givers.

Context: Nature of Statutory Criteria/ Case Summary:  The enrollees representative is requesting reimbursement and authorization and coverage for residential treatment center services. The enrollee has diagnoses of moderate recurrent major depressive disorder, combined presentation attention deficit hyperactivity disorder, intermittent explosive disorder, nicotine dependence, cannabis use disorder, and alcohol abuse. The Child and Adolescent Level of Care Utilization System (CALOCUS) developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. This tool was used in this review. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. For risk of harm, the enrollees score is 3, as he has no active suicidal or homicidal ideation, but he displays extreme distress and there is a history of suicidal/homicidal behavior. For functional status the enrollees score is 2, as the enrollee demonstrates significant improvement in function following a period of deterioration. For comorbidity the enrollees score is 2, due to the presence of transient, occasional, stress-related psychiatric symptoms that have no discernable impact on his presenting condition. For recovery environment level of stress, the enrollees score is 3, due to exposure to substance abuse and its effects. For recovery environment level of support, the enrollees score is 2, as the family/primary caretakers are willing and able to participate in treatment if requested to do so and have the capacity to effect needed changes. For resiliency and treatment history the enrollees score is 3, since previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. Also, developmental pressures and life changes have caused some deterioration in function. For acceptance and engagement the enrollees score is 2, as the enrollee has developed a positive therapeutic relationship with clinicians and other primary care givers. The enrollees composite CALOCUS score is 17, which correlates with high intensity community-based services, as provided at the intensive outpatient program (IOP) level.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.

Question: What is the background context in this case summary?


Answer: The patient has requested authorization and coverage for dilation and curettage (D&C). Although this patient initially presented postpartum with evidence of retained products of conception, after administration of Misoprostol the patient no longer had evidence of retained products of conception. An ultrasound performed after the patient underwent treatment with Misoprostol revealed that there were no remaining products of conception.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dilation and curettage (D&C). Although this patient initially presented postpartum with evidence of retained products of conception, after administration of Misoprostol the patient no longer had evidence of retained products of conception. An ultrasound performed after the patient underwent treatment with Misoprostol revealed that there were no remaining products of conception. The requested D&C is no longer medically necessary. The patient has no heavy bleeding, fever or pain. Proceeding with a D&C would be more harmful than beneficial. Therefore, the requested D&C without general anesthesia is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: An enrollee has requested reimbursement for the 10 prenatal genetic tests  Foresight Carrier Screen.

Context: An enrollee has requested reimbursement for the 10 prenatal genetic tests  Foresight Carrier Screen. The American College of Medical Genetics and Genomics (ACMGG) recommends offering carrier screening for cystic fibrosis to all female patients using a 23-mutation panel. The American College of Obstetricians and Gynecologists (ACOG) also recommends carrier screening for cystic fibrosis and spinal muscular atrophy to all patients of childbearing age. The expanded carrier screening is efficient, as it includes carrier screening for cystic fibrosis, and spinal muscular atrophy. Given this patients age and family history, the 10 prenatal genetic tests  Foresight Carrier Screen were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the 10 prenatal genetic tests  Foresight Carrier Screen.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician reviewers 1, 2, and 3 are board certified in genetics and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The patient has requested authorization and coverage for Eversense continuous glucose monitor (CGM).

Answer: In this case, the patient has had difficulties with the Dexcom and Freestyle Libre CGM in terms of accuracy and in maintaining the sensor in place, given his active lifestyle at work and during exercise. The patient also has documentation of hypoglycemia unawareness.

Context: The patient has requested authorization and coverage for Eversense continuous glucose monitor (CGM). The Eversense real time CGM system consists of a subcutaneously inserted sensor, a wearable transmitter, and a smartphone application. The sensor longevity is achieved using multiple approaches, including the chemical structure of the glucose binding polymer, the platinum coating, the dexamethasone acetate eluting ring, and the subcutaneous position in comparison to transcutaneous real time CGM systems. The U.S. Food and Drug Administration (FDA) approved the Eversense CGM in 2018. There are multiple peer-reviewed studies and published literature attesting to the Eversense CGM accuracy, and its superiority to the Dexcom and the Freestyle Libre CGM devices. In a recent study that compared the three CGM systems, the point accuracy of the Eversense was significantly better than two other CGM systems. In this case, the patient has had difficulties with the Dexcom and Freestyle Libre CGM in terms of accuracy and in maintaining the sensor in place, given his active lifestyle at work and during exercise. The patient also has documentation of hypoglycemia unawareness. The Eversense CGM is implantable subcutaneously, which also supports superior accuracy when compared to Dexcom and Freestyle Libre CGM devices, and helps keep the sensor in place. All told, the requested Eversense CGM is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The enrollee is requesting authorization and coverage for the medication Zepatier. The enrollee has a history of Hepatitis C. She was treated with Interferon-based therapy. She achieved a high viral response from this treatment, but her viral loads are now high.  A sonogram of the liver showed normal hepatic elasticity. Laboratory results showed moderately elevated liver enzymes. She has a metavir score of FO-1.

Answer: The recent progress note documents her gastroenterologist recommended Zepatier because she has had Interferon treatment in the past. The health plan has denied authorization, indicating Zepatier is covered for the treatment of chronic Hepatitis C, genotype 1 for patients that have compensated liver disease by fibroscan ultrasound or biopsy documenting stage 2,3, or 4 fibrosis, NS5A resistance testing is required.  For the treatment of Hepatitis C, the preferred agents are Epclusa, Harvoni, and Vosevi. The enrollee has a history of hepatitis C and was previously treated with interferon.  The genotype is reported to be 1a.  She does not have cirrhosis.

Context: Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication Zepatier. The enrollee has a history of Hepatitis C. She was treated with Interferon-based therapy. She achieved a high viral response from this treatment, but her viral loads are now high.  A sonogram of the liver showed normal hepatic elasticity. Laboratory results showed moderately elevated liver enzymes. She has a metavir score of FO-1. This places her in the absent-to-mild fibrosis, low-risk category for significant fibrosis/stenosis. The recent progress note documents her gastroenterologist recommended Zepatier because she has had Interferon treatment in the past. The health plan has denied authorization, indicating Zepatier is covered for the treatment of chronic Hepatitis C, genotype 1 for patients that have compensated liver disease by fibroscan ultrasound or biopsy documenting stage 2,3, or 4 fibrosis, NS5A resistance testing is required.  For the treatment of Hepatitis C, the preferred agents are Epclusa, Harvoni, and Vosevi. The enrollee has a history of hepatitis C and was previously treated with interferon.  The genotype is reported to be 1a.  She does not have cirrhosis. Professional societies  recommended Zepatier as a treatment for HCV genotype 1a, interferon-experienced persons; but only if they do not have resistance variants.  To utilize this medication regimen, resistance testing needs to be performed.  There was insufficient evidence in the record that resistance testing was performed. Epclusa, an alternative medication, is also a recommended regimen for HCV genotype 1a interferon-experienced patients and does not require resistance testing.   Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.

Question: What is the background context in this case summary?


Answer: The enrollee is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee entered a residential treatment center (RTC) for treatment of heroin addiction. The enrollee reported he was mentally exhausted. He started opiates in high school, and heroin at 17-18 years old. Since the start of heroin use, he has accumulated approximately five years of sobriety. He noted his heroin use was due to pain. He was involved in an accident which exacerbated his pre-existing sciatic pain and added significant thoracic and shoulder pain. He had past success with Methadone and Suboxone and remained abstinent when adhering to his medication regimen. This admission is his sixth time in treatment. The discharge recommendation was an intensive outpatient program and sober living. The enrollee reports using two grams of heroin a day for two years. Prior to this, he was sober for a year and a half. The enrollee describes a history of depression and insomnia, but he stated he was never diagnosed. However, he had been prescribed Seroquel and Ativan. He was taking Gabapentin for pain from a motor vehicle accident two years ago. He has no history of suicidal ideation (SI), homicidal ideation (HI), self-harming behaviors, or auditory and visual hallucinations. He denied a history of seizure or blackouts. After admission, he was placed on an opioid withdrawal protocol and was receiving Clonidine, Imodium, Baclofen, Vistaril and Suboxone; when indicated.

Answer: He shows significant deterioration in his ability to fulfill responsibilities and obligations to job, school, self, or significant others; which may be avoided or neglected on some occasions.

Answer: He may occasionally experience psychiatric symptoms which are related to stress, medical illness, or substance use, but they are transient and have no discernable impact on the co-existing substance use disorder.

Answer: At least partial recovery has been maintained for moderate periods of time, but only with strong professional or peer support or in structured settings.

Answer: The enrollee shows some recognition of his personal role in recovery and accepts some responsibility for it.

Context: Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee entered a residential treatment center (RTC) for treatment of heroin addiction. The enrollee reported he was mentally exhausted. He started opiates in high school, and heroin at 17-18 years old. Since the start of heroin use, he has accumulated approximately five years of sobriety. He noted his heroin use was due to pain. He was involved in an accident which exacerbated his pre-existing sciatic pain and added significant thoracic and shoulder pain. He had past success with Methadone and Suboxone and remained abstinent when adhering to his medication regimen. This admission is his sixth time in treatment. The discharge recommendation was an intensive outpatient program and sober living. The enrollee reports using two grams of heroin a day for two years. Prior to this, he was sober for a year and a half. The enrollee describes a history of depression and insomnia, but he stated he was never diagnosed. However, he had been prescribed Seroquel and Ativan. He was taking Gabapentin for pain from a motor vehicle accident two years ago. He has no history of suicidal ideation (SI), homicidal ideation (HI), self-harming behaviors, or auditory and visual hallucinations. He denied a history of seizure or blackouts. After admission, he was placed on an opioid withdrawal protocol and was receiving Clonidine, Imodium, Baclofen, Vistaril and Suboxone; when indicated.  The Clinical Opiate Withdrawal Scale (COWS) is used to assess the progress and severity of withdrawal and to guide medication administration. Scores of 5-12 indicate mild withdrawal, 13-24 indicate moderate withdrawal, 25-26 indicate moderately severe withdrawal, and over 36 indicate severe withdrawal. His initial COWS score was 11 and his last was 3. The Level of Care Utilization System (LOCUS), level of care assessment tool, applied in review of this case indicates for risk of harm, the enrollees score is 2, due to substance use without significant episodes of potentially harmful behaviors. For functional status, the enrollees score is 3, due to significant disturbances in vegetative activities such as sleep, eating habits, activity level, or sexual appetite which do not pose a serious threat to health. He shows significant deterioration in his ability to fulfill responsibilities and obligations to job, school, self, or significant others; which may be avoided or neglected on some occasions. For comorbidity, the enrollees score is 2, due to the existence of medical problems which are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. He may occasionally experience psychiatric symptoms which are related to stress, medical illness, or substance use, but they are transient and have no discernable impact on the co-existing substance use disorder. For recovery environment level of stress, the enrollees score is 3, due to a significant transition causing disruption in life circumstances; such as job loss, legal difficulties or change of residence, and easy exposure and access to alcohol and drugs. For recovery environment level of support, the enrollees score is 2, because supportive resources are not abundant, but are capable of and willing to provide significant aid in times of need. For treatment and recovery history, the enrollees score is 3, because previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. At least partial recovery has been maintained for moderate periods of time, but only with strong professional or peer support or in structured settings. For engagement and recovery status, the enrollees score is 2, due to willingness to change. The enrollee shows some recognition of his personal role in recovery and accepts some responsibility for it. The enrollees composite LOCUS score is 17, which correlates with high intensity community-based services. Medical evidence does not support the services at issue in this clinical setting. Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.

Question: What is the background context in this case summary?


Answer: An enrollees parent has requested authorization and coverage for double mastectomy with nipple reconstruction.

Answer: In this case, the patient has a long history of gender dysphoria, and he has been living as male, on testosterone. The patient has substantial documentation from the medical team at his gender clinic program as well as from psychologists of gender dysphoria regarding his chest, and documentation of clinically significant symptoms supporting the medical necessity of bilateral mastectomy with male chest reconstruction.

Context: Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for double mastectomy with nipple reconstruction.The World Professional Association for Transgender Health (WPATH), a worldwide authority on transgender health issues, has stated that chest surgery in transgender male patients is often of greater practical significance in the patient's daily life than reconstruction of the genitals (WPATH 2016). The WPATH Standard of Care, version 7, clearly mentions that chest surgery in Female to Male (FTM) patients could be carried out earlier than the age of majority. Mastectomy with male chest reconstruction in transgender male youth is now commonly done in minors, and has been demonstrated to be a safe and effective treatment for gender dysphoria in this population. In this case, the patient has a long history of gender dysphoria, and he has been living as male, on testosterone. The patient has substantial documentation from the medical team at his gender clinic program as well as from psychologists of gender dysphoria regarding his chest, and documentation of clinically significant symptoms supporting the medical necessity of bilateral mastectomy with male chest reconstruction. Under these circumstances, the requested double mastectomy with nipple reconstruction is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The patient has requested authorization and coverage for Radicava

Answer: The medical records provided for review support that this patient has a diagnosis of ALS. The available medical records are consistent with a progressive disorder that is progressing in terms of affecting his neurologic ability

Answer: This patient is able to ambulate with the use of assistive devices.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Radicava. Radicava is U.S. Food and Drug Administration (FDA) approved to slow decline and loss of physical function in patients with amyotrophic lateral sclerosis (ALS). A study found that medical trials demonstrated beneficial improvement on functional ability and slowing clinical decline in ALS with Radicava. Study extension results published also reflected positive benefit of Radicava for treatment of ALS. The medical records provided for review support that this patient has a diagnosis of ALS. The available medical records are consistent with a progressive disorder that is progressing in terms of affecting his neurologic ability. However, the patients ALS Functional Rating Scale (ALSFRS) (ALSFRS) score should reflect a score two for walking ability, not a one, as noted in the records. A score of two is appropriate when a patient can walk with assistance. A score of one denotes only non-ambulatory functional movement. This patient is able to ambulate with the use of assistive devices. As such, all of the elements of the ALSFRS at the time medication was to be started were two or greater, which supports an indication for Radicava. Moreover, the timeframe of diagnosis was less than two years ago, as recommended by the guidelines. As such, the medical records demonstrate that the patient meets the recommendations in the medical literature for the treatment with Radicava. Therefore, treatment with Radicava is medical necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The patient has requested authorization and coverage for Dexcom G6 continuous glucose monitor (CGM) with alerts. Based on the records provided for review, this patient has brittle insulin dependent diabetes due to her lack of pancreas as noted by the provider. Specifically, the patient has no beta cells to produce insulin or alpha cells to produce glucagon. Her glucose levels fluctuate widely, especially due to chemotherapy every two weeks for pancreatic cancer. In addition, she has neuropathy. Risk of hypoglycemia would place the patient at risk for neuroglycopenic symptoms, confusion, and loss of consciousness.

Answer: the patient is

Answer: insulin sensitive, such that small doses of insulin can make large changes in her glucose levels. For these reasons, the provider recommended the Tandem T-slim pump, which requires the patient to make decisions based on glucose levels, and self-adjust her insulin doses. The Tandem T-slim device works with the Dexcom G6 CGM, which communicates wirelessly with the Tandem T-slim insulin pump, in order to act with a predictive suspension of insulin delivery when the patients glucose levels are starting to drop fast into hypoglycemia range.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dexcom G6 continuous glucose monitor (CGM) with alerts. Based on the records provided for review, this patient has brittle insulin dependent diabetes due to her lack of pancreas as noted by the provider. Specifically, the patient has no beta cells to produce insulin or alpha cells to produce glucagon. Her glucose levels fluctuate widely, especially due to chemotherapy every two weeks for pancreatic cancer. In addition, she has neuropathy. Risk of hypoglycemia would place the patient at risk for neuroglycopenic symptoms, confusion, and loss of consciousness. Moreover, the patient is extremely insulin sensitive, such that small doses of insulin can make large changes in her glucose levels. For these reasons, the provider recommended the Tandem T-slim pump, which requires the patient to make decisions based on glucose levels, and self-adjust her insulin doses. The Tandem T-slim device works with the Dexcom G6 CGM, which communicates wirelessly with the Tandem T-slim insulin pump, in order to act with a predictive suspension of insulin delivery when the patients glucose levels are starting to drop fast into hypoglycemia range. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The patient has requested Synvisc One injections.

Answer: The patient has had an excellent response to past viscosupplementation injections with nine months of pain relief following each series of injections.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested Synvisc One injections. Findings: The physician reviewer found that medical evidence supports that Synvisc One injections are medically necessary. The patient has had an excellent response to past viscosupplementation injections with nine months of pain relief following each series of injections. A review of current medical literature pertaining to viscosupplementation reveals mixed results. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. Current research reports that intra-articular hyaluronic acid (IAHA) provides a moderate symptomatic benefit for patients with knee osteoarthritis, without major safety concerns. IAHA may offer one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee OA health outcomes, overall gain in quality-adjusted life years and substantial delays in time to total knee replacement. In this case, there is evidence of benefit from prior injections. Moreover, the options are limited, with the alternative being a total knee arthroplasty. Medical evidence supports the services at issue in this clinical setting. Therefore, Synvisc One injections are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: An enrollee has requested reimbursement for partial hospitalization program services.

Answer: The patient showed variable insight into her behaviors. She was withdrawn in group sessions at times.

Answer: The patients family was involved in her treatment on a regular basis, and she denied illicit substance use.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes do not indicate that the patient had active suicidal or homicidal ideation. The records do not demonstrate that the patient was experiencing psychosis. The patient showed variable insight into her behaviors. She was withdrawn in group sessions at times. The progress notes do not indicate that the patient was engaging in aggressive behaviors. The patients family was involved in her treatment on a regular basis, and she denied illicit substance use. In cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to problems with role performance and ability to maintain some meaningful relationships. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and no substance use issues. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living situation with intermittent interpersonal conflict. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources but also some difficulty in relationships with her family members. With regards to treatment and recovery history, the records support a score of 3 due to recent success at the inpatient and residential treatment levels of care but without complete remission of the eating disorder symptoms. In terms of engagement and recovery status, the records support a score of 2 to 3 due to cooperation in treatment but also hesitation in acceptance of her illness. Thus, the patient has a composite score of 14 to 15. This score correlates with high intensity community based services, or treatment in an intensive outpatient clinic setting. Therefore, partial hospitalization program services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The patient has advanced chronic kidney disease from autosomal dominant polycystic kidney disease (ADPKD) and is being evaluated for a renal transplant.

Answer: the patients records indicated the possibility of a diagnosis of an intracranial aneurysm

Context: Nature of Statutory Criteria/Case Summary: The patient has advanced chronic kidney disease from autosomal dominant polycystic kidney disease (ADPKD) and is being evaluated for a renal transplant. A review of the patients records indicated the possibility of a diagnosis of an intracranial aneurysm, which is common in patients with ADPKD. The risk of bleeding from such an aneurysm is significant. Therefore, any anticoagulation in patients with ADPKD must be undertaken cautiously. Studies demonstrated that renal transplantation in ADPKD is associated with more thromboembolic complications. In addition, ADPKD is a risk factor for Factor V Leiden mutations. Standard clotting analysis could fail to identify a clotting tendency risk. Identifying the risk allows for the appropriate plan of action for securing the best outcome.Findings:  Two out of three physician reviewers found that studies demonstrated that renal transplantation in ADPKD is associated with more thromboembolic complications. In addition, ADPKD is a risk factor for Factor V Leiden mutations. Standard clotting analysis could fail to identify a clotting tendency risk. Identifying the risk allows for the appropriate plan of action for securing the best outcome.Final Result: The reviewers determined that the requested tests were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in nephrology, and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: An enrollee has requested reimbursement for the high intensity focused ultrasound (HIFU) prostate ablation procedure that was performed. The Health Plan has denied the services at issue as investigational for treatment of the enrollees prostate cancer.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the high intensity focused ultrasound (HIFU) prostate ablation procedure that was performed. The Health Plan has denied the services at issue as investigational for treatment of the enrollees prostate cancer.Findings:  Three physician reviewers found that high-intensity focused ultrasound (HIFU) has been widely used for whole gland ablation. The first published results of focal HIFU are promising. The patient's quality of life and potency are well preserved with good early results. Whole-gland HIFU is a repeatable day-case treatment that confers low rates of urinary incontinence. Disease control at a median of just under five years of follow-up demonstrates its potential as a treatment for nonmetastatic prostate cancer. Endoscopic interventions and erectile dysfunction rates are similar to other whole-gland treatments. The U.S. Food and Drug Administration (FDA) has approved HIFU as safe for the treatment of prostate ablation. However, there is no specific indication for the treatment of prostate cancer. Furthermore, the safety and efficacy of chemical or surgical cytoreduction of the prostate remains unproven. The safety and efficacy of HIFU are currently being evaluated. There is a paucity of long-term comparative clinical trials indicating that this form of treatment is superior to conventional treatment options. Thus, the HIFU prostate ablation procedure that was performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested procedure was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The patient has chronic low back pain, sciatica, chronic neck pain and cervical radiculopathy. The patient was treated with acupuncture for his conditions. He was diagnosed with chronic spondylosis and stenosis of the entire spine. He has degenerative disc disease through the cervical spine and the lower lumbar spine. He underwent three epidural injections, utilized opioid pain medications, tried physical therapy, and started acupuncture. He had 18 treatments of acupuncture for the cervical radiculopathy and left shoulder pain, which helped his left shoulder pain and somewhat improved his chronic upper back pain. He also had eight treatments of acupuncture for his thoracic spine pain and leg myalgia, which helped his leg pain somewhat but not his buttocks and mid back. Per a report, the patient has worsening neck and left upper extremity pain of seven to eight out of 10, and acupuncture only helps temporarily.

Answer: He indicates that he experienced temporary relief with treatments.

Answer: The patient has been referred for surgical management due to the lack of relief of conservative measures.

Context: Nature of Statutory Criteria/Case Summary: The patient has chronic low back pain, sciatica, chronic neck pain and cervical radiculopathy. The patient was treated with acupuncture for his conditions. He was diagnosed with chronic spondylosis and stenosis of the entire spine. He has degenerative disc disease through the cervical spine and the lower lumbar spine. He underwent three epidural injections, utilized opioid pain medications, tried physical therapy, and started acupuncture. He had 18 treatments of acupuncture for the cervical radiculopathy and left shoulder pain, which helped his left shoulder pain and somewhat improved his chronic upper back pain. He also had eight treatments of acupuncture for his thoracic spine pain and leg myalgia, which helped his leg pain somewhat but not his buttocks and mid back. Per a report, the patient has worsening neck and left upper extremity pain of seven to eight out of 10, and acupuncture only helps temporarily. The patient has received sufficient acupuncture treatment to his neck and low back. He has not reportedly made any sustained and significant improvement after 26 total treatments with two different providers. He indicates that he experienced temporary relief with treatments. However, he is not reasonably expected to make further sustained improvement through more treatment. Acupuncture is an effective short-term treatment for patients with chronic neck pain. However, there is only limited evidence for long-term effects. Also, studies show that acupuncture is not clinically more effective than sham-acupuncture or placebo for neck or back pain. The patient has been referred for surgical management due to the lack of relief of conservative measures. Acupuncture is not supported as medically necessary for his condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a board certified chiropractor licensed in oriental medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The enrollee has requested reimbursement for residential treatment center (RTC) services that were provided from 12/12/18 through 12/16/18. The patient was admitted to the RTC service on 11/17/18 and was discharged on 12/17/18. Her diagnoses included alcohol use disorder.

Context: Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for residential treatment center (RTC) services that were provided from 12/12/18 through 12/16/18. The patient was admitted to the RTC service on 11/17/18 and was discharged on 12/17/18. Her diagnoses included alcohol use disorder. The American Psychiatric Association (APA) treatment guidelines for Substance Use Disorders recommends that RTC or similar care that is higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In addition, the American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay, moving from program-driven to clinically driven and outcomes-driven treatment. The ASAM criteria is a set of objective guidelines used by providers to assist with treatment planning. The ASAM advocates for services provided in the least intensive, but safe treatment setting possible for each individual patient. The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce the risk of relapse. The RTC was in accordance with generally accepted standards of medical practice.This patients risks included her living alone without a support system in place. She required a safe and stable living environment in order to develop her recovery skills, and thus qualified for ASAM Level III treatment, which is consistent with the services provided at the RTC. Therefore, the RTC services provided from 12/12/18 through 12/16/18 were medically necessary to treat the patients behavioral health condition.Final Result: The reviewer determined that the requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: An enrollee has requested reimbursement for genetic testing.

Answer: this patient does not have a reported personal or family history of clotting disorders

Context: An enrollee has requested reimbursement for genetic testing. Although antiphospholipid syndrome has been associated with early pregnancy loss, routine testing for other thrombophilias is not recommended by the American College of Obstetricians and Gynecologists (ACOG). In addition, this patient does not have a reported personal or family history of clotting disorders to warrant testing for thrombophilias. According to the ACOG practice bulletin, no work-up generally is recommended until after the second consecutive clinical early pregnancy loss. Specifically, ACOG noted that maternal or fetal chromosomal analyses or testing for inherited thrombophilias are not recommended routinely after one early pregnancy loss. Further, from the American Society for Reproductive Medicine (ASRM), routine testing of women with recurrent pregnancy loss for inherited thrombophilias is not recommended. Accordingly, the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services.

Answer: the patient had some potential for risk of harm, for she is noted to have had a history of serious harm to others and suicidal ideation and covert preparation for self-harm or suicide

Answer: the patient had been neglecting her ADLs and had a history of a previous shutdown

Answer: the patient has a significant comorbidity, sensory integration disorder

Answer: The patients recovery environment  level of stress score reflects a highly stressful environment

Answer: The patients recovery environment  level of support score reflects that the patients recovery support was limited

Answer: The patients resilience and treatment history score

Answer: and her acceptance and engagement  child/adolescent score

Answer: were adversely affected by her non-adherence and repeated rejection of therapists, along with multiple relapses. The patients acceptance and engagement  parent/primary caretaker score appeared destructive

Answer: due to their competition.

Context: Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters 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. Regarding the six CALOCUS dimensions, the patient had some potential for risk of harm, for she is noted to have had a history of serious harm to others and suicidal ideation and covert preparation for self-harm or suicide (score = 3). Regarding functional status, the patient had been neglecting her ADLs and had a history of a previous shutdown (score = 4). Regarding comorbidity, the patient has a significant comorbidity, sensory integration disorder (score = 3). The patients recovery environment  level of stress score reflects a highly stressful environment (score = 4). The patients recovery environment  level of support score reflects that the patients recovery support was limited (score = 4). The patients resilience and treatment history score (score = 4) and her acceptance and engagement  child/adolescent score (score = 4) were adversely affected by her non-adherence and repeated rejection of therapists, along with multiple relapses. The patients acceptance and engagement  parent/primary caretaker score appeared destructive (score = 4) due to their competition. This represents a composite CALOCUS score of 26 at the time of admission to the RTC. The patient therefore met CALOCUS criteria on the date of admission to residential treatment center services. After treatment, however, the patient no longer met CALOCUS criteria for a continued RTC stay. The CALOCUS score after admission was 18, with marked improvement in the patient's daily functioning and engagement and acceptance of treatment; especially her willingness to continue Lexapro, which had improved her mood and anxiety. The patients family appeared much more prepared to continue therapy and to be supportive. Therefore, the RTC services provided during the patients admission were medically necessary for treatment of the patients medical condition. The RTC services following the patients 12th month of admission to the RTC were not, and are not, medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that some of requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The physician reviewer found that an enrollee has requested authorization and coverage for the medication frovatriptan succinate 2.5mg

Answer: In this case, the patient has tried and failed with sumatriptan and rizatriptan. The patients chronic migraine headaches have improved with zolmitriptan. Zolmitriptan, however, has not been effective for migraine exacerbations during the patients menstrual cycles, as documented in the providers letter dated 11/01/18.

Context: Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for the medication frovatriptan succinate 2.5mg. The submitted documentation supports the medical necessity of the requested medication. Menstrual migraine is defined as migraine without aura that occurs within days -2 and +3 of the menstrual period on at least 2 of 3 consecutive menstrual cycles (where menstruation onset is defined as day 1). Studies have stated that evidence from frovatriptan studies meets the AAN threshold for a Level A recommendation for short-term use to prevent menstrual migraine. Researchers recommend frovatriptan as effective for menstrual headaches. In this case, the patient has tried and failed with sumatriptan and rizatriptan. The patients chronic migraine headaches have improved with zolmitriptan. Zolmitriptan, however, has not been effective for migraine exacerbations during the patients menstrual cycles, as documented in the providers letter dated 11/01/18. Under these circumstances, frovatriptan succinate 2.5mg is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: The parent of an enrollee has requested reimbursement for residential treatment services.

Answer: The medical records indicate that the patient was not actively suicidal during the disputed timeframe, and he did not engage in self-harm behaviors.

Answer: The patient had some issues with level of function prior to residential treatment center placement, but the progress notes indicate significant improvement after a period of deterioration. The progress notes indicate he performed his activities of daily living as well as chores at the treatment center on a regular basis. He was also noted to help peers with their chores.

Answer: The patient had asthma issues which were exacerbated by wildfires in the area near the residential treatment center. The records did not indicate a history of substance use, and he did not have a substance use diagnosis.

Answer: The patient was not noted to have interpersonal conflict with the family members.

Answer: The patients parents were involved in treatment on a regular basis.

Answer: During the dates of service in dispute, the patient showed cooperative behavior and attitude. The progress notes indicated that he was open and honest with regards to his feelings about his peers at the treatment center, who appeared to be his major focus of stress. He did not display aggression towards peers or staff during the disputed timeframe. The patient did not express significant depression or anxiety symptoms. He did not express symptoms of psychosis. He indicated that his medications were working for him, and his focus was good.

Answer: The patient had a good response to a short period in the residential treatment center prior to the disputed dates.  His presentation during the disputed timeframe indicates that he was cooperative in treatment. He had failed prior treatment at the outpatient and partial hospitalization program levels of care.

Answer: The patient participated in therapy actively, and his insight and judgment into his issues with his peer relationships appeared to improve as his treatment progressed.

Answer: The parents worked actively and constructively with clinicians on a regular basis.

Context: Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. During the dates of service in dispute, the patient showed cooperative behavior and attitude. The progress notes indicated that he was open and honest with regards to his feelings about his peers at the treatment center, who appeared to be his major focus of stress. He did not display aggression towards peers or staff during the disputed timeframe. The patient did not express significant depression or anxiety symptoms. He did not express symptoms of psychosis. He indicated that his medications were working for him, and his focus was good.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 necessary level of care for children. In terms of risk of harm, the records support a score of 1. The medical records indicate that the patient was not actively suicidal during the disputed timeframe, and he did not engage in self-harm behaviors. With regards to functional status, the records support a score of 2. The patient had some issues with level of function prior to residential treatment center placement, but the progress notes indicate significant improvement after a period of deterioration. The progress notes indicate he performed his activities of daily living as well as chores at the treatment center on a regular basis. He was also noted to help peers with their chores. In terms of comorbidity, the records support a score of 2. The patient had asthma issues which were exacerbated by wildfires in the area near the residential treatment center. The records did not indicate a history of substance use, and he did not have a substance use diagnosis. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was not noted to have interpersonal conflict with the family members. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. The patient had a good response to a short period in the residential treatment center prior to the disputed dates.  His presentation during the disputed timeframe indicates that he was cooperative in treatment. He had failed prior treatment at the outpatient and partial hospitalization program levels of care. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy actively, and his insight and judgment into his issues with his peer relationships appeared to improve as his treatment progressed. In terms of acceptance and engagement of the parents, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 16. This score correlates with outpatient services. Therefore, residential treatment services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: An enrollee has requested authorization and coverage for MRI of silicone breast implants.

Answer: In this case, the patient has previously undergone bilateral mastectomy and reconstruction with silicone implants for a left breast cancer. Due to a past silent rupture found on MRI, she underwent implant exchange with silicone implants. At this time, the patient's current silicone implants have not received MRI screening for silent rupture in seven years.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MRI of silicone breast implants. The U.S. Food & Drug Administration (FDA) recommends that persons who have silicone gel-filled breast implants receive MRI screening for silent rupture 3 years after receiving their implant, and every 2 years after that. A study found that MRI is the modality of choice, if it is available. Their study found that the diagnostic accuracy of magnetic resonance imaging was significantly higher than that of ultrasound (94 percent versus 72 percent; p < 0.0001), and states, [M]agnetic resonance imaging should be considered the investigation of choice for implant rupture where the resource is available. However, if magnetic resonance imaging is contraindicated or unavailable, ultrasound can be considered as an alternative method. In this case, the patient has previously undergone bilateral mastectomy and reconstruction with silicone implants for a left breast cancer. Due to a past silent rupture found on MRI, she underwent implant exchange with silicone implants. At this time, the patient's current silicone implants have not received MRI screening for silent rupture in seven years. Based on the entirety of the medical documentation, MRI of silicone breast implants is medically necessary for treatment of the patients medical condition at this time.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: An enrollee has requested authorization and coverage for corneal transplant with laser to be performed at one location, instead of two.

Context: An enrollee has requested authorization and coverage for corneal transplant with laser to be performed at one location, instead of two. The submitted documentation supports the medical necessity of the requested services. While there is a paucity of studies that have specifically compared laser keratoplasty procedure performed at two different sites versus one site, transporting the patient from one site to another during the procedure does add a small risk to the procedure. Therefore, in order to minimize risk of any harm to the patient, the one site procedure is recommended. Thus, the requested corneal transplant with laser to be performed at one location, instead of two, is medically necessary for the treatment of this patient.

Question: What is the background context in this case summary?


Answer: The parent of a female enrollee has requested authorization and coverage for Aptiom (eslicarbazepine acetate) 800 mg.  The patient has refractory localization-related epilepsy that has come under control with Aptiom 800mg and Keppra.

Answer: other anticonvulsants are available on the Health Plan formulary

Context: Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested authorization and coverage for Aptiom (eslicarbazepine acetate) 800 mg.  The patient has refractory localization-related epilepsy that has come under control with Aptiom 800mg and Keppra. Although other anticonvulsants are available on the Health Plan formulary, it is unknown whether any other monotherapy or combination antiepileptic drug regimen would control the patient's seizures. In 30-year review of 1795 patients with newly diagnosed epilepsy, colleagues stated that Most patients who attain control do so with the first or second antiepileptic drug. The probability of achieving seizure freedom diminishes substantially with each subsequent antiepileptic drug regimen tried. More than one-third of patients experience epilepsy that remains uncontrolled. Colleagues noted that epilepsy associated with tumors is generally poorly controlled by antiepileptic drugs. Colleagues explained that Aptiom (eslicarbazepine acetate) is effective in the treatment of refractory partial seizures in children, and that it is well tolerated from a neurocognitive and behavioral standpoint. Therefore, Aptiom 800 mg is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology, with special qualification in pediatric neurology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: A female enrollee has requested reimbursement for the serological antibody blood test.

Context: Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the serological antibody blood test. Confirmation of eradication should be performed in patients treated for H. pylori due to increasing antibiotic resistance. Based on the current medical guidelines, eradication can be confirmed with a urea breath test, stool antigen testing, or endoscopy-based testing. The choice of test depends on the need for an upper endoscopy. Tests to confirm eradication should be performed at least four weeks after completion of antibiotic treatment. However, there is a lack of data supporting a role for serologic testing to confirm eradication, as patients may continue to have antibodies after eradication, and this leads to false positive results. Accordingly, the serological antibody blood test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the serological antibody blood test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

Question: What is the background context in this case summary?


Answer: An enrollee has requested authorization and coverage for Orthovisc injections to the right and left knee.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections to the right and left knee. The submitted documentation demonstrates the medical necessity of the requested services. The current literature supports the use of viscosupplementation for osteoarthritis of the knees. The current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. In this patients case, prior viscosupplementation was beneficial. Therefore, the requested Orthovisc injections to the right and left knee are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Findings:  The physician reviewer found that

Question: What is the background context in this case summary?