Answer: A 60-year-old male enrollee requested services provided on an emergent basis.

Answer: The patient presented with reported symptoms of itching and jaundice for more than 20 days.

Context: A 60-year-old male enrollee requested services provided on an emergent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention.  The patient presented with reported symptoms of itching and jaundice for more than 20 days. There is no documentation during this pre-hospitalization window, nor immediately following hospitalization, of hemodynamic instability, respiratory compromise, or shock which might necessitate emergent treatment. In addition, the records do not support that an emergency medical condition existed at the onset of symptoms or in the early days of hospitalization.  All told, the patients symptoms did not meet prudent layperson criteria for emergency care.

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


Answer: A 63-year-old male enrollee requested Sovaldi 400mg in combination with peginterferon and ribavirin for 12 weeks for medical treatment of his hepatitis C.

Context: A 63-year-old male enrollee requested Sovaldi 400mg in combination with peginterferon and ribavirin for 12 weeks for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested regimen in this clinical setting.  It is medically appropriate to treat the patient before complications of liver disease occur.  Current national guidelines support treatment in this patients case.  Thus, Sovaldi 400mg in combination with peginterferon and ribavirin for 12 weeks is medically indicated for the treatment of this patient.

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


Answer: A 27-year-old female enrollee requested a  hospital stay for treatment of her pregnancy.

Answer: the patient presented to the labor and delivery department with an acute history of an abnormal NST.

Context: A 27-year-old female enrollee requested a  hospital stay for treatment of her pregnancy.  Findings:  The physician reviewer found that the patient presented to the labor and delivery department with an acute history of an abnormal NST. The NST is based on the premise that the heart rate of a fetus that is not acidotic or neurologically depressed will temporarily accelerate with fetal movement. Heart rate reactivity is considered a good indicator of normal fetal autonomic function. Loss of reactivity is most commonly associated with a fetal sleep cycle but may result from any cause of central nervous system depression, including fetal acidemia. The NST results are categorized as reactive or nonreactive. As noted by the American College of Obstetricians and Gynecologists (ACOG), the most common definition of a reactive, or normal, NST is if there are two or more fetal heart rate accelerations within a 20 minute period. A nonreactive NST is one that lacks sufficient fetal heart rate accelerations over a 40 minute period. In the absence of obstetric contraindications, delivery of the fetus with an abnormal test result may be performed by induction of labor, with continuous intrapartum monitoring of the fetal heart rate and uterine contractions. The finding of an abnormal fetal heart rate pattern, including tachycardia and arrhythmia in this patient, may indicate fetal distress. Fetal distress is an emergent condition requiring acute care of the mother and fetus. The records indicate this patent required inpatient admission to undergo obstetrical triage at this facility. However, the patient could have been evaluated at an adjacent obstetrical triage unit prior to consideration for immediate inpatient admission. If abnormal fetal surveillance was found at that time, then the patient could have been admitted for acute management. Consistent with these findings, the hospital stay was not medically necessary for treatment of this patients medical condition.

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


Answer: A 47-year-old female enrollee has requested right ankle platelet rich plasma (PRP) tissue grafting for treatment of her right ankle pain.

Context: A 47-year-old female enrollee has requested right ankle platelet rich plasma (PRP) tissue grafting for treatment of her right ankle pain.  Findings:  Three physician reviewers found that according to an article in the American Academy of Orthopaedic Surgeons (AAOS), the literature on the clinical use of PRP suggests that considerable variability exists in its effectiveness, even in the same clinical setting. Available data indicates that PRP may be valuable in enhancing soft tissue repair and in wound healing. However, the clinical role of PRP in bone repair remains controversial. Delos and colleagues reported that there are no definite indications for the use of PRP. In the absence of scientific data demonstrating the safety and effectiveness of PRP for treatment of painful ankle conditions, the PRP tissue grafting was not likely to provide this patient with an improved health outcome when compared to standard available alternatives.

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


Answer: A 66-year-old male enrollee has requested AlloMap testing for evaluation of his status post orthotopic cardiac transplantation.

Context: A 66-year-old male enrollee has requested AlloMap testing for evaluation of his status post orthotopic cardiac transplantation. Findings:  Two physician reviewers found that the testing at issue was likely to have been superior over other methods of evaluating this patient.  There is support for gene expression profiling using AlloMap testing for acute cellular rejection screening in appropriate low-risk patients who are between six months and five years post transplant.  The current medical evidence supports the testing at issue in this clinical setting.  In this patients case, AlloMap testing was consistent with well-established guidelines for postoperative management and follow-up.  Therefore, AlloMap testing was consistent with current standard of care and was likely to have been more beneficial for this patient than standard therapy.

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


Answer: A 63-year-old female enrollee has requested a semi-electric hospital bed, gel mattress overlay and rails for treatment of her medical condition.

Answer: The patient has various respiratory conditions

Context: A 63-year-old female enrollee has requested a semi-electric hospital bed, gel mattress overlay and rails for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Semi-electric or fully electric hospital beds may be necessary if an individual requires head elevation or has other frequent positioning needs and is unable to perform these maneuvers independently.  Pressure relieving mattresses may be needed if an individual is unable to perform sufficient pressure relief independently.  However, the submitted records do not establish that the patient has any impairment that would require a semi-electric hospital bed, gel mattress overlay or bed rails.  The patient has various respiratory conditions, but no documented objective need to have the head of the bed frequently elevated.  She has no documented neurological or musculoskeletal conditions that would preclude self-repositioning in bed for her pain conditions.  There are no impairments, major risk factors for pressure ulcers, or other medical conditions that establish the need for a gel mattress overlay.  There are no impairments that need to be addressed with rails on a semi-electric bed.  All told, the requested semi-electric hospital bed, gel mattress overlay and rails are not medically necessary for the treatment of this patient.

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


Answer: A 32-year-old male enrollee has requested anterior lumbar interbody fusion with instrumentation at L5-S1 for treatment of his lumbar pain.

Context: A 32-year-old male enrollee has requested anterior lumbar interbody fusion with instrumentation at L5-S1 for treatment of his lumbar pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. To fuse the lumbar spine in the absence of dynamic instability, more than 2 mm on flexion/extension views or severe spinal stenosis for the lumbar spine, is not consistent with standards of good medical practice. In addition, randomized trials have not demonstrated the efficacy of surgical treatment in chronic low back pain and disc degeneration. Brox and colleagues demonstrated conservative care to be equal to lumbar fusion with a return to work rate at 22% in the surgical group compared with 33% in the non-surgical group. The authors concluded that the overall success rates were equivalent. Fairbank and colleagues performed a randomized controlled trial of spinal fusion versus rehabilitation for patients with chronic low back pain and reported no differences between the groups. Finally, in this patients case, there is no evidence of instability or severe spinal stenosis to warrant a lumbar fusion at the L5-S1 level. Based on the medical literature and the documentation submitted for review, the requested procedure is not medically necessary for treatment of the patients medical condition.

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


Answer: A 19-year-old female enrollee has requested continued inpatient hospitalization for treatment of her behavioral health conditions.

Answer: During the admission, the patient began to develop insight regarding underlying family dynamics which represented a reasonable long-term therapeutic focus.  The diagnostic assessment, which included both major depression and bipolarity, had not changed.  Her medications were well-tolerated.  The patient was sleeping well and eating most of her meals.  She posed no behavioral disturbances on the unit and was not cognitively impaired or psychotic.  On the specified date, the patient was active in discharge planning while nursing reported no suicidal ideation or urge to self-harm.  The physician notes indicated suicidal ideation, with no history of attempt, which had not changed from admission.

Context: A 19-year-old female enrollee has requested continued inpatient hospitalization for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation does not support continued inpatient hospitalization from the specified date forward.  During the admission, the patient began to develop insight regarding underlying family dynamics which represented a reasonable long-term therapeutic focus.  The diagnostic assessment, which included both major depression and bipolarity, had not changed.  Her medications were well-tolerated.  The patient was sleeping well and eating most of her meals.  She posed no behavioral disturbances on the unit and was not cognitively impaired or psychotic.  On the specified date, the patient was active in discharge planning while nursing reported no suicidal ideation or urge to self-harm.  The physician notes indicated suicidal ideation, with no history of attempt, which had not changed from admission.  In sum, by the specified date, there was no evidence of an acute psychiatric syndrome necessitating continued inpatient hospitalization.  All told, continued inpatient hospitalization from the specified date forward was not and is not medically indicated for the treatment of this patient.

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


Answer: The parent of a 10-year-old male enrollee has requested indirect consultation for treatment of the enrollees autism and speech and language delays.

Answer: the patient is non-verbal and intellectually disabled. At the age of eight his language comprehension and expressive skill was between 6 and 8 months age equivalency.

Answer: since the advent of a picture communication system his comprehension of language has markedly improved.

Context: The parent of a 10-year-old male enrollee has requested indirect consultation for treatment of the enrollees autism and speech and language delays.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested services. Based on the documentation submitted, the patient is non-verbal and intellectually disabled. At the age of eight his language comprehension and expressive skill was between 6 and 8 months age equivalency. However, since the advent of a picture communication system his comprehension of language has markedly improved. Thus, a picture exchange system is the treatment of choice for this patient. According to the study by Kaiser and Roberts, speech impaired children whose parents are directly involved with the childs speech therapy simultaneously with the therapist have improved language outcomes compared with parents who are independently instructed. Thus, it is important that the patients parent receive instruction of the picture communication system.  Engaging the mother actively within the therapy and spending a few minutes of each hour in parental instruction is medically reasonable and sufficient.

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


Answer: A 58-year-old female enrollee has requested Supartz injections (right knee) for treatment of her osteoarthritis.

Context: A 58-year-old female enrollee has requested Supartz injections (right knee) for treatment of her osteoarthritis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested services in this clinical setting.  There have been double-blinded studies which do not document clinical effect from hyaluronan injection.  Additionally, there is a documented incidence of aseptic inflammatory reactions due to allergic response and a risk of iatrogenic infection within the joint.  Rutjes and colleagues performed a meta-analysis to evaluate the risks and benefits of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors noted that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects.  All told, the requested Supartz injections are not medically indicated for the treatment of this patient.

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


Answer: A 35-year-old male enrollee has requested endoscopic piriformis release surgery for treatment of the enrollees piriformis syndrome.

Answer: this patient presents with chronic pain. However, his pain generator has not been identified.

Answer: the patient has not reportedly received substantial relief after piriformis injection.

Context: A 35-year-old male enrollee has requested endoscopic piriformis release surgery for treatment of the enrollees piriformis syndrome.  Findings:  The physician reviewer found that this patient presents with chronic pain. However, his pain generator has not been identified. He has normal neurologic and orthopedic examinations and there is a lack of documentation by examination to substantiate a diagnosis of piriformis syndrome. In addition, the patient has not reportedly received substantial relief after piriformis injection. In the medical literature, Filler noted that before surgery is considered, two successful blocks should have been received. Further, there are no large, prospective, scientific studies that have shown the efficacy of this surgery. Only small, retrospective studies are reported (Benson and Schutzer). There is no large body of literature that supports the diagnosis of piriformis syndrome. Campbell and Landau noted that, there is little definite evidence in the literature to support the diagnosis of piriformis syndrome. Miller and colleagues noted that, diagnosis is hampered by lack of agreed upon clinical criteria and lack of definitive investigation such as imaging or electrodiagnostic studies. Thus, any surgery on this patients sciatic nerve for piriformis syndrome is not supported as medically necessary.

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


Answer: A 39-year-old female enrollee has requested outpatient psychotherapy for treatment of her behavioral health condition.

Answer: The patient has received more than three years of weekly psychotherapy treatment

Answer: the patient remains symptomatic.

Context: A 39-year-old female enrollee has requested outpatient psychotherapy for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the outpatient psychotherapy provided from the date indicated forward was not and is not medically necessary for this patients medical condition. The patient has received more than three years of weekly psychotherapy treatment; the patients notes reflect no measurable improvements, treatment goals or attainable discharge dates. Despite the therapy received to date, the patient remains symptomatic. According to Gelenberg and colleagues, For psychotherapy, treatment should be reassessed if there has not been a meaningful improvement after a few months. Patients should be reassessed every 3-4 months to ensure adequate improvement. Regardless of treatment modality, lack of improvement over time warrants reconsideration of interventions. Continued weekly insight-oriented sessions are not consistent with the standard of care in this setting. All told, the services at issue have not produced any measurable gains or improvement and continued use of this modality at this frequency is not medically necessary.

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


Answer: A 23-year-old male enrollee has requested residential treatment center services for treatment of his polysubstance dependence.

Answer: The patient expressed motivation for sobriety and the need for trauma therapy was also identified. He was described as contemplative and in the preparation stage of change during his first week of treatment.

Answer: the patient did not attend his nutritional assessment, and failed to participate in group therapy sessions. The patient did not take his medication as prescribed and elected to skip groups.

Context: A 23-year-old male enrollee has requested residential treatment center services for treatment of his polysubstance dependence.  Findings:  The physician reviewer found that based on the records provided for review, residential treatment center services were medically necessary for treatment of this patients medical condition from the time frame specified. Modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, resilience and mental wellness. The American Psychiatric Association (APA) supports residential treatment 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 and lack sufficient social and vocational skills. Based on this guidance, residential placement was initially reasonable for this patient as his life was dominated by substance use. The patient expressed motivation for sobriety and the need for trauma therapy was also identified. He was described as contemplative and in the preparation stage of change during his first week of treatment. However, the patient did not attend his nutritional assessment, and failed to participate in group therapy sessions. The patient did not take his medication as prescribed and elected to skip groups. Consistent with the APA recommendations, the residential treatment services were medically necessary from the time frame specified, but are not supported as medically necessary during the subsequent time frame.

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


Answer: A 53-year-old male enrollee has requested daily use of Cialis 5mg for treatment of his medical condition.

Answer: The medical records noted that there were no lower urinary tract symptoms (LUTS)

Answer: the patient indicates that he has BPH

Context: A 53-year-old male enrollee has requested daily use of Cialis 5mg for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. In this patients case, the clinical notes do not document the diagnosis of benign prostatic hypertrophy (BPH). The medical records noted that there were no lower urinary tract symptoms (LUTS), which is a symptom of BPH. Moreover, BPH has not been fully evaluated or addressed as there is no documentation of a digital rectal exam, which should be done to diagnose BPH. Although the patient indicates that he has BPH, the urologists diagnosis did not indicate BPH, and the current medical evidence does not support daily use of Cialis 5mgin this setting. All told, daily use of Cialis 5mg is not medically indicated for the treatment of this patient.

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


Answer: The parent of a 16-year-old male enrollee has requested 22 hours a week of direct applied behavioral analysis (ABA) treatment, 12 hours a month of supervision and 6 hours a week of parent consultation for treatment of the enrollees autistic disorder.

Answer: This 16-year-old patient has been receiving ABA therapy for at least 7 years.

Context: The parent of a 16-year-old male enrollee has requested 22 hours a week of direct applied behavioral analysis (ABA) treatment, 12 hours a month of supervision and 6 hours a week of parent consultation for treatment of the enrollees autistic disorder.  Findings:  The physician reviewer found that the medical communitys customary and usual prescription for an autistic child is ABA therapy. Multiple studies have documented ABA therapy as significantly improving motor, verbal, and social interactive skills in autistic children. The value of ABA as the only effective behavioral treatment has been documented by multiple authors (Vismara and Rogers). However, when reviewing ABA as effectively applied to teenagers and adults, there is limited literature addressing the question of duration and frequency of therapy as the patient reaches adolescence and adulthood. Rather than to continue individual ABA therapy, the tendency is to expand social and behavioral skills in group and school settings.  This 16-year-old patient has been receiving ABA therapy for at least 7 years. While intensive ABA services are not likely to result in further significant improvement, continuation of ABA therapy at a reduced frequency is medically necessary to maintain the patients current level of function. As such, continued ABA therapy at a frequency of 5 hours per week of direct ABA therapy, 1 hour per week of supervision and 1 hour per month of parent consultation is medically necessary to maintain the patients present level of function.

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


Answer: A 60-year-old male enrollee has requested continued posterior tibial neurostimulation (percutaneous tibial nerve stimulation) for treatment of his benign prostatic hyperplasia with urinary frequency.

Answer: This patient has

Answer: symptomatic benign prostatic hyperplasia

Context: A 60-year-old male enrollee has requested continued posterior tibial neurostimulation (percutaneous tibial nerve stimulation) for treatment of his benign prostatic hyperplasia with urinary frequency. Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other available treatment options.  This patient has subjective and objective evidence of symptomatic benign prostatic hyperplasia.  Percutaneous tibial nerve stimulation is not indicated in this clinical setting.  Per the medical records, this patient has not received standard treatment for benign prostatic hyperplasia.  All told, continued percutaneous tibial nerve stimulation is not likely to be more efficacious than other modalities for the treatment of this patient.

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


Answer: A 46-year-old female enrollee has requested a panniculectomy for the treatment of her excess skin.

Answer: The medical records note that the patient has a skin condition which has been resistant to medications, and the pannus hangs below the pubis.

Context: A 46-year-old female enrollee has requested a panniculectomy for the treatment of her excess skin. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  Panniculectomy involves the removal of the lower abdominal skin without the muscle tightening or supraumbilical skin tightening via periumbilical and lower abdominal incisions of an abdominoplasty.  Per the submitted photographs, this patients pannus skin fold has resulted in a disruption of skin integrity.  The medical records note that the patient has a skin condition which has been resistant to medications, and the pannus hangs below the pubis.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested panniculectomy is medically indicated for the treatment of this patient.

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


Answer: A 36-year-old female enrollee has requested custom molded orthotics, cast supplies, application of short leg splint, and follow-up podiatry visit for treatment of the enrollees plantar fasciitis.

Answer: this patients heel pain has not resolved with use of nonsteroidal anti-inflammatory medications and over-the-counter arch supports.  She has partially responded to a local steroid injection and medial arch strapping.

Context: A 36-year-old female enrollee has requested custom molded orthotics, cast supplies, application of short leg splint, and follow-up podiatry visit for treatment of the enrollees plantar fasciitis. Findings:  The physician reviewer found that this patients heel pain has not resolved with use of nonsteroidal anti-inflammatory medications and over-the-counter arch supports.  She has partially responded to a local steroid injection and medial arch strapping.  In this clinical setting, given the biomechanical pathology, the current medical evidence supports custom molded orthotics.  The use of custom molded orthotics is an established treatment for overpronation and heel pain.  In this patients case, the requested custom molded orthotics and follow-up podiatry visit are medically indicated.  However, cast supplies and application of short leg splint are not medically necessary.  The progress notes do not support the need for a short leg splint or cast supplies.  All told, the submitted documentation demonstrates the medical necessity of a portion of the requested services.

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


Answer: The parent of a 13-year-old female has requested applied behavioral analysis (ABA) therapy that incorporates Discrete Trial Training, task analysis, Pivotal Response Training, incidental teaching methods, and group activity for treatment of autism.

Context: The parent of a 13-year-old female has requested applied behavioral analysis (ABA) therapy that incorporates Discrete Trial Training, task analysis, Pivotal Response Training, incidental teaching methods, and group activity for treatment of autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder (Granpeesheh, et al). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Multiple studies of Lovaas-based approaches and early intensive behavioral intervention variants resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Sallows and Graupner). Individual treatment is a defining feature and integral component of ABA. The Individual Program Plan for this patient is constructed to identify all behavioral needs including communication, functional living, self-help skills, social interaction, and recreation. These domains are noted as program components for intensive ABA therapy. All told, the ABA therapy incorporating Discrete Trial Training, task analysis, Pivotal Response Training, incidental teaching methods, and group activity, is medically necessary for treatment of this patients medical condition.

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


Answer: A 22-year-old female has requested laser hair removal for treatment of her polycystic ovarian syndrome.

Answer: the medical records indicate that the patient has been diagnosed with polycystic ovarian syndrome and hirsutism.  She is currently being treated with Aldactone

Context: A 22-year-old female has requested laser hair removal for treatment of her polycystic ovarian syndrome.   Findings:  The physician reviewer found that the medical records indicate that the patient has been diagnosed with polycystic ovarian syndrome and hirsutism.  She is currently being treated with Aldactone, which is a potassium-sparing diuretic that has anti-androgen properties.  This medication can help excessive hair growth.  In this patients case, it has not been established that the excessive hair constitutes an abnormal structure of the body.  The submitted documentation does not indicate the distribution of hair that the patient wishes to remove.  Additionally, there is no evidence of any associated functional deficit produced by the excessive hair growth.  All told, the requested laser hair removal is not reconstructive in nature and is not medically necessary in this patients case.

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


Answer: A 57-year-old male has requested approval for an increase in medications (Zoloft back to 100mg, three times per day, gabapentin 300mg, three times per day, and Vicodin 5/500mg, six times per day) for treatment of his chronic pain and depression.

Answer: He has a known chronic pain condition and is on treatment with multiple medications, including narcotics.  Sources of chronic pain include neuropathic pain, visceral pain, and musculoskeletal pain.

Answer: Per the medical documentation, the patient has a signed Controlled Substance Contract with his provider.  The records indicate that the patient tested positive for codeine and morphine, and these medications were not prescribed by the treating provider.

Context: A 57-year-old male has requested approval for an increase in medications (Zoloft back to 100mg, three times per day, gabapentin 300mg, three times per day, and Vicodin 5/500mg, six times per day) for treatment of his chronic pain and depression.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantities in this patients case.  He has a known chronic pain condition and is on treatment with multiple medications, including narcotics.  Sources of chronic pain include neuropathic pain, visceral pain, and musculoskeletal pain.  Per the current medical evidence, treatment approaches can include combinations of medical therapy, behavioral intervention, interventional therapies, and rehabilitative interventions.  The current medical research indicates that treatment with narcotic analgesics for a period of greater than two weeks does not result in more favorable pain control than the use of non-steroidal anti-inflammatories or acetaminophen. Many studies have documented the high degree of comorbidity between depression and chronic pain, and there is evidence that the incidence of depression among patients with chronic pain is higher than for other chronic illnesses.  Per the medical documentation, the patient has a signed Controlled Substance Contract with his provider.  The records indicate that the patient tested positive for codeine and morphine, and these medications were not prescribed by the treating provider.  This constitutes a breach in his signed Controlled Substance Contract.  The current medical evidence does not support the requested increase in medications in this clinical setting.  All told, the requested increase in medications (Zoloft back to 100mg, three times per day, gabapentin 300mg, three times per day, and Vicodin 5/500mg, six times per day) is not medically indicated for the treatment of this patient.

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


Answer: A 67-year-old female has requested coverage for transportation for treatment of congestive heart failure, chronic obstructive pulmonary disease, obesity, and hypertensive heart disease.

Answer: The clinical notes indicate that the patient is able to ambulate without documented deficits

Context: A 67-year-old female has requested coverage for transportation for treatment of congestive heart failure, chronic obstructive pulmonary disease, obesity, and hypertensive heart disease.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services in this clinical setting.  The medical records do not demonstrate the medical necessity of non-emergency transportation in this patients case.  There is no documentation indicating that she requires transportation other than by means of public or private conveyance.  She has no specific impairments which require transportation to and from medical visits.  The clinical notes indicate that the patient is able to ambulate without documented deficits, and she has no medical condition which requires structured transportation.  All told, the requested transportation is not medically indicated in this case.

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


Answer: The representative of a 45-year-old male has requested admission to an acute rehabilitation facility that specializes in brain injuries for treatment of his medical condition status post brain aneurysm and intracerebral hemorrhage.

Answer: the patient has sustained a severe brain injury.

Answer: This patients medical condition currently is one of severe brain injury and chronic ventilator dependence. He is at high risk for recurrent pneumonia but does not have multiple organ dysfunction.

Answer: he continues to have severe brain injury and ventilator dependence more than three months post-stroke.

Context: The representative of a 45-year-old male has requested admission to an acute rehabilitation facility that specializes in brain injuries for treatment of his medical condition status post brain aneurysm and intracerebral hemorrhage.   Findings:  The physician reviewer found that based on review of the available records, the patient has sustained a severe brain injury. His hospitalization with severe pneumonia in underscores the severity of his illness. The medical literature, including Eskildsen and colleagues review, discuss the indications for long-term acute care. Specifically, the authors noted that a patient needs to have an unstable condition with a need for multiple specialists providing frequent care. This patients medical condition currently is one of severe brain injury and chronic ventilator dependence. He is at high risk for recurrent pneumonia but does not have multiple organ dysfunction. In addition, he continues to have severe brain injury and ventilator dependence more than three months post-stroke. He is unable to make gains consistent with intense rehabilitation. He will need a protracted course with rehabilitation with small gains expected over a long period of time. The anticipated benefit from acute rehabilitation follows from progressive recovery from brain injury. The degree of this patients brain injury prohibits him from progressing with intensive therapy at this time. All told, the requested services are not supported as medically necessary in treating this patients medical condition.

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


Answer: The parent of a 5-year-old female enrollee has requested coverage for applied behavioral analysis (ABA) therapy for 35 hours per week for treatment of the enrollees global developmental delay and autism spectrum disorder.

Answer: Based on review of the available records, both the patients pediatric neurologist and her clinical psychologist diagnosed her as autistic and independently recommended 20 to 35 hours of ABA therapy.

Context: The parent of a 5-year-old female enrollee has requested coverage for applied behavioral analysis (ABA) therapy for 35 hours per week for treatment of the enrollees global developmental delay and autism spectrum disorder.  Findings:  The physician reviewer found that Based on review of the available records, both the patients pediatric neurologist and her clinical psychologist diagnosed her as autistic and independently recommended 20 to 35 hours of ABA therapy. The patients intellectual disability is a frequent co-morbid diagnosis in autistic children. However, this condition does not preclude the patient from benefitting extensively from ABA therapy. ABA therapy is well-documented as the only consistently successful intervention for autistic children. The medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has a documented 40-year track record of substantially improving motor, verbal, and socially interactive skills in autistic children. Myers and Johnson indicate that the effectiveness of ABA-based intervention in autism spectrum disorder has been well-documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Further, the authors report that, children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. This patient has been diagnosed as autistic, for which ABA therapy is the well-documented therapy of choice. There is consensus among clinical psychologists that ABA therapy should be intensively initiated as soon as a diagnosis of autism is established. With regard to the appropriate frequency of ABA therapy, at the requested 35 hours per week of ABA services, there would be inadequate time to develop group socialization or trials of mainstreaming the patient during school hours. A frequency of 20 hours of ABA therapy per week is more appropriate in this setting. All told, it is medically necessary that ABA therapy be continued for this patient. However, the recommendation is for 20 hours of ABA therapy per week.

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


Answer: A 43-year-old female has requested aquatic therapy for treatment of her Dercums disease and lymphedema.

Context: A 43-year-old female has requested aquatic therapy for treatment of her Dercums disease and lymphedema.  Findings:  The physician reviewer found that based on review of the available records, the patient has a severe and rare debilitating condition that requires a multifaceted approach for effective treatment. The medical literature indicates that clinical benefits from an aquatics program include improvement in strength, mobility, and overall well-being. Consistent with this support, this patient would benefit from a therapeutic aquatic exercise program. Given the significant pain and limited mobility associated with her condition, aquatic therapy is medically necessary.

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


Answer: A 63-year-old male enrollee has requested for gastric Lap-band surgery for treatment of her obesity.

Context: A 63-year-old male enrollee has requested for gastric Lap-band surgery for treatment of her obesity. Findings:  The physician reviewer found that the medical records do not document completion of a multidisciplinary evaluation, including a dietary evaluation, behavioral evaluation, and medical evaluation.  In the absence of this documentation, the medical necessity of the requested procedure cannot be established.  Additionally, failed weight loss efforts should be documented prior to the requested surgery.  All told, the requested gastric Lap-band surgery is not medically indicated for the treatment of this patient at this time.

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


Answer: A 62-year-old female enrollee has requested for chiropractic services for treatment of her left hip and low back pain.

Answer: the patient remains symptomatic

Context: A 62-year-old female enrollee has requested for chiropractic services for treatment of her left hip and low back pain. Findings:  The physician reviewer found that there is no clinically significant benefit with respect to analgesic, health or functional outcomes is expected with chiropractic therapy at this time based on the available clinical data.  There is no proven benefit of chiropractic treatment in the setting of chronic low back pain, chronic hip pain, or other musculoskeletal conditions.  In the review by Ernst and colleagues, the authors concluded that rigorous clinical trials have not demonstrated that chiropractic care is an effective intervention for pain control.  In 2008, Bronfort and colleagues did not note significant, sustained benefit to spinal manipulation and mobilization over other conservative management.  Although the patient remains symptomatic, the requested chiropractic therapy is not reasonably expected to provide significant clinical benefit beyond an ongoing physical therapy program or an independent exercise program.  All told, the requested chiropractic services are not medically indicated for the treatment of this patient.

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


Answer: A 48-year-old female enrollee has requested for gastric bypass surgery for treatment of her obesity.

Context: A 48-year-old female enrollee has requested for gastric bypass surgery for treatment of her obesity.  Findings:  The physician reviewer found that based on review of the records, medical necessity has not been established for the requested bariatric surgery procedure. As noted in the medical literature by Smith and colleagues, Emerging data support the role of bariatric surgery as an effective treatment for improvement or remission of type 2 diabetes, hypertension, dyslipidemia, and multiple other comorbid conditions that accompany obesity. This patients records do not document any of these conditions.  Accordingly, the requested surgery is not medically necessary for treatment of the patients medical condition.

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


Answer: A 42-year-old female enrollee has requested authorization and coverage for removal of breast implants for treatment of a ruptured breast implant.

Context: A 42-year-old female enrollee has requested authorization and coverage for removal of breast implants for treatment of a ruptured breast implant. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Removal of breast implants would be considered medically necessary for the treatment of active infection, impending or actual implant extrusion, painful symptomatic grade IV capsular contracture, or leakage of silicone gel.  The existence of any of these conditions is not documented in the reviewed materials.  It is unlikely that a deflated saline implant in the absence of grade IV capsular contracture or infection would cause any functional deficit.  Based on the information provided, removal of breast implants is not medically necessary for the treatment of this patient. Given the absence of high-grade capsular contracture, capsulectomy is also not medically necessary.

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


Answer: A 60-year-old female has requested transcranial magnetic stimulation therapy (30 sessions of acute treatments, 5 sessions of tapering of transcranial magnetic stimulation and coverage of the initial treatment evaluation) for treatment of her major depressive disorder.

Answer: the patient's provider reported that the patient has been resistant to treatment with multiple trials of psychopharmacologic agents, including Emsam patch, Elavil, Cymbalta, Lexapro, Prozac, Effexor, Remeron, Zoloft, Abilify, nortriptyline, Luvox, Desyrel, Celexa, imipramine, Paxil, Wellbutrin, and Pristiq.  The patient reported thoughts of suicide, anhedonia, cognitive impairment, interpersonal withdrawal, difficulty sleeping, suicidal ideation, irritability, fatigue, and weight changes.  The provider noted that the patient had electroconvulsive therapy in the past, with no response.

Answer: This patient has

Answer: undergone 25 sessions of electroconvulsive therapy, with no response.  Her prior medications have included combinations of antidepressants, mood stabilizers, and anti-anxiety medications.  Psychotherapy and cognitive therapy have also been provided.  The patient continues to be symptomatic.

Context: A 60-year-old female has requested transcranial magnetic stimulation therapy (30 sessions of acute treatments, 5 sessions of tapering of transcranial magnetic stimulation and coverage of the initial treatment evaluation) for treatment of her major depressive disorder.  Findings:  Three physician reviewers found that the patient's provider reported that the patient has been resistant to treatment with multiple trials of psychopharmacologic agents, including Emsam patch, Elavil, Cymbalta, Lexapro, Prozac, Effexor, Remeron, Zoloft, Abilify, nortriptyline, Luvox, Desyrel, Celexa, imipramine, Paxil, Wellbutrin, and Pristiq.  The patient reported thoughts of suicide, anhedonia, cognitive impairment, interpersonal withdrawal, difficulty sleeping, suicidal ideation, irritability, fatigue, and weight changes.  The provider noted that the patient had electroconvulsive therapy in the past, with no response.  In this patients case, the requested services are likely to be of greater benefit than other available treatment alternatives.  The American Psychiatric Association has noted that transcranial magnetic stimulation is an appropriate acute phase treatment option for patients who do not respond to medication therapy.  This patient has already undergone 25 sessions of electroconvulsive therapy, with no response.  Her prior medications have included combinations of antidepressants, mood stabilizers, and anti-anxiety medications.  Psychotherapy and cognitive therapy have also been provided.  The patient continues to be symptomatic.  In this clinical setting, transcranial magnetic stimulation is likely to be more beneficial than other treatment modalities.  All told, the requested transcranial magnetic stimulation therapy (30 sessions of acute treatments, 5 sessions of tapering of transcranial magnetic stimulation and coverage of the initial treatment evaluation) is likely to be superior over other treatment options in this patients case.

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


Answer: The parent of a four-year-old male has requested occupational therapy for treatment of his eating disorder.

Context: The parent of a four-year-old male has requested occupational therapy for treatment of his eating disorder.  Findings:  The physician reviewer found that feeding difficulties are common in early life with 25% of children reported to have some form of feeding disorder. Consequences of feeding disorders can be severe, including growth failure and susceptibility to chronic illness. Feeding disorders occur in children who are healthy, who have gastrointestinal disorders, and in those with special needs. Caretto and colleagues evaluated the role of occupational therapists in parent education of infant feeding in the neonatal intensive care unit. The occupational therapists were most frequently identified as responsible for teaching about positioning, infant development, and infant states and cues and were highly involved in educating parents about feeding. Although this study involved neonates, this does prove that occupational therapists have a role in the treatment of feeding problems and are the main providers in the treatment of feeding disorders. Most feeding disorders have underlying organic causes. However, overwhelming evidence indicates that abnormal feeding patterns are not solely due to organic impairment. As such, feeding disorders should be conceptualized on a continuum between psychosocial and organic factors. Disordered feeding in a child is seldom limited to the child alone and is oftentimes a family problem. Assessment and treatment are best conducted by an interdisciplinary team of professionals. At minimum, the team should include a gastroenterologist, nutritionist, behavioral psychologist, and occupational and/or speech therapist. Intervention should be comprehensive and include treatment of the medical condition, behavioral modification to alter the patients inappropriate learned feeding patterns, and parent education and training in appropriate parenting and feeding skills. A majority of feeding problems can be resolved or greatly improved through medical, oromotor, and behavioral therapy. For these reasons, the requested occupational therapy is medically necessary to prevent malnourishment, failure to thrive, and to reduce morbidity in the treatment of this patients medical condition.

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


Answer: The parent of a two-year-old male enrollee has requested  for speech therapy for treatment of the enrollees speech delay.

Context: The parent of a two-year-old male enrollee has requested  for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.

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


Answer: A 28-year-old male enrollee has requested coverage for past emergency services provided.

Answer: the patient sought emergency services for complaints of left eye redness, swelling and pain. He had a history of a chalazion for several months. Approximately a week prior to his visit to the emergency room, he developed increased swelling to the chalazion in his left eye. He applied warm compresses which he continued for one week with little improvement in his symptoms.  The patient left for a vacation and while away, the pain and swelling in his eyelid increased and there was a small amount of discharge. The patient sought medical attention at an emergency room. He had no fever and there was no loss of vision. The swelling was contained to his eyelid. The infection was drained and the patient was placed on antibiotic ophthalmic ointment.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention.

Context: A 28-year-old male enrollee has requested coverage for past emergency services provided.  Findings:  The physician reviewer found that the patient sought emergency services for complaints of left eye redness, swelling and pain. He had a history of a chalazion for several months. Approximately a week prior to his visit to the emergency room, he developed increased swelling to the chalazion in his left eye. He applied warm compresses which he continued for one week with little improvement in his symptoms.  The patient left for a vacation and while away, the pain and swelling in his eyelid increased and there was a small amount of discharge. The patient sought medical attention at an emergency room. He had no fever and there was no loss of vision. The swelling was contained to his eyelid. The infection was drained and the patient was placed on antibiotic ophthalmic ointment.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention.  California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Chalazions are not acute medical emergencies. They are typically managed with warm compresses and antibiotic ointment with referral to an ophthalmologist when that fails.  In this case, the patient reports he experienced a significant worsening of pain and swelling and that his vision was blurry. The emergency physician record indicates that the patients pain in the emergency room was 2-3 out of 10 and his visual acuity was 20/20. The patient did not require narcotic analgesia. He received Motrin for pain. All told, the objective medical record documentation does not support the contention that the patient experienced a significant worsening of pain, swelling and vision problems at the time he sought emergency services. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health and thus would not have sought immediate medical attention for the patients complaints.

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


Answer: The parent of a seven-year-old male has requested a mitochondrial muscle biopsy for evaluation of his stated condition of a possible metabolic/mitochondrial disorder.

Context: The parent of a seven-year-old male has requested a mitochondrial muscle biopsy for evaluation of his stated condition of a possible metabolic/mitochondrial disorder.  Findings:  The physician reviewer found that this patient has ASD but does not exhibit other symptoms to suggest a mitochondrial disorder. Signs of mitochondrial disease include elevations of lactic acid, which the patient does demonstrate.  However, blood lactate and pyruvate measurements are known to be prone to erroneous increases due to such issues as prolonged tourniquet application, (see Bonini, et al. and Haas). Other biochemical markers are often present including elevation of plasma alanine in the amino acids, elevations of urine organic acids and especially dicarboxylic acids due to omega oxidation of fat in the cytoplasm when mitochondria are not functioning normally.  Elevations of acylcarnitine derivatives are usually seen, as well.  Ammonia can also be elevated with mitochondrial disease (Haas). The patient exhibited none of these biochemical markers. Finally, patients with mitochondrial diseases usually have progressive deterioration in their neurological functioning (Haas) which is also not evident in the documentation provided regarding this patient. Therefore, without additional signs or symptoms as outlined above, a muscle biopsy for the purpose of a mitochondrial disease work-up is not medically necessary for the patient.

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


Answer: A 45-year-old male enrollee has requested Interferon Alpha injections for treatment of his Peyronies Disease.

Context: A 45-year-old male enrollee has requested Interferon Alpha injections for treatment of his Peyronies Disease. Findings:  The physician reviewer found that the literature evidences that the etiology of Peyronies Disease is not clearly understood, however the effect of the disease is a plaque that affects the elasticity of the corporal body. This results in non-uniform distension of the corporeal bodies which leads to a curvature of the erection. The surgical treatment of the plaque is still considered to be the standard method of treatment when a patients disease is determined to be stable and mature (Gordon). As with other methods of treatment for Peyronies Disease, Interferon therapy requires further investigation to define its efficacy, proper dosing regimens and side-effect profiles (Larsen & Levine). In sum, the requested medication is not considered medically necessary in this setting, as this treatment modality is still being evaluated and is not considered to be an accepted option for treatment of the patients medical condition.

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


Answer: A 61-year-old female enrollee has requested for emergency services indicating emergency care.

Answer: complaints including cough, chills, body aches, vomiting and abdominal pain.The patient was diagnosed with an upper respiratory infection. The patients condition did not improve and she sought medical attention at a facility.

Context: A 61-year-old female enrollee has requested for emergency services indicating emergency care. Findings:  The physician reviewer found that complaints including cough, chills, body aches, vomiting and abdominal pain.The patient was diagnosed with an upper respiratory infection. The patients condition did not improve and she sought medical attention at a facility.

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


Answer: A 20-year-old male enrollee has requested a prosthetic running limb for treatment of his status post an above-the-knee amputation.

Answer: The patient currently uses a prosthesis that allows him to accomplish his mobility-related activities of daily living

Context: A 20-year-old male enrollee has requested a prosthetic running limb for treatment of his status post an above-the-knee amputation.  Findings:  The physician reviewer found that this patient has goals of competing in the 2012 Paralympics, and he has requested a prosthetic running limb. Prostheses for running are specially adapted for this task.  However, these adaptations are not necessary for an individual to accomplish basic mobility-related activities of daily living. The patient currently uses a prosthesis that allows him to accomplish his mobility-related activities of daily living, including community mobility. The requested equipment adds to the patients options for exercise and recreation, but it is not medically necessary.  The submitted medical records do not demonstrate the medical necessity of the requested equipment.  All told, the requested prosthetic running limb is not medically indicated.

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


Answer: The parent of a 7-year-old female enrollee has requested 30 hours per week of applied behavior analysis (ABA) therapy services for treatment of the enrollees autism.

Context: The parent of a 7-year-old female enrollee has requested 30 hours per week of applied behavior analysis (ABA) therapy services for treatment of the enrollees autism. Findings:  The physician reviewer found that this patient with autism will continue to benefit from intensive ABA therapy and has shown impressive gains in all domains since the start of treatment. The American Academy of Pediatrics (AAP) recommends a minimum of 25 hours per week of ABA therapy per week for children with autism. As this is the standard of care for patients with autism, 25 hours per week of ABA therapy is medically necessary for the management of this patients behavioral issues associated with autism.

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


Answer: The parent of a two-year-old male enrollee has requested speech therapy services for treatment of the enrollees speech/language delay.

Context: The parent of a two-year-old male enrollee has requested speech therapy services for treatment of the enrollees speech/language delay.  Findings:  The physician reviewer found that approximately 5% of preschool children will exhibit speech and language delay. There is evidence that preschool children with developmental speech and language disorders are at increased risk for difficulty with reading when they enter school.  The current medical evidence indicates that early intervention can improve speech and language skills.  Recent studies have reported an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, given the degree of his speech and language delay, the requested speech therapy is standard of care. There is sufficient medical evidence supporting the requested services in this clinical scenario.  All told, the requested speech therapy services are medically indicated for the treatment of this patient.

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


Answer: A 38-year-old female enrollee has requested an MRI scan of the breast for her history of Lynch syndrome/HNPCC and metastatic colorectal cancer to the liver.

Answer: the provider states that there is a lifetime risk of breast cancer of approximately 20%

Context: A 38-year-old female enrollee has requested an MRI scan of the breast for her history of Lynch syndrome/HNPCC and metastatic colorectal cancer to the liver.  Findings:  Two physician reviewers found that Lynch syndrome (hereditary non-polyposis colorectal cancer) is characterized by the development of colorectal cancer, endometrial cancer and various other cancers.  Protocols for surveillance in Lynch syndrome include colonoscopy, gynecological examinations, which may include regular ultrasounds and biopsies, and abdominal ultrasound screening.  The American College of Radiology has recognized the increased sensitivity of MRI for high-risk patients.  Clinical situations in which breast MRI may be warranted include patients with BRCA mutations, patients who are untested but who have a first-degree relative with BRCA mutations and patients with a lifetime risk of breast cancer of 20 to 25% or greater as defined by BRCAPRO or other models that are largely dependent on family history. This patient does meet established criteria for breast MRI.  Although the provider states that there is a lifetime risk of breast cancer of approximately 20%, this cannot be established based upon any given model.  All told, the requested MRI of the breast is not likely to be superior over other methods of evaluation.

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


Answer: The parent of a 15-year-old female enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature.

Answer: the patient has normal growth factors and pituitary function on laboratory testing.  IGF-1 and IGFBP-3 levels were normal, and serum chemistries were normal.

Context: The parent of a 15-year-old female enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the patient has normal growth factors and pituitary function on laboratory testing.  IGF-1 and IGFBP-3 levels were normal, and serum chemistries were normal.  She has no complaints or symptoms of pituitary insufficiency and no history of pituitary abnormality.  There is no evidence of growth hormone deficiency.  All told, in this patients case, the requested Genotropin growth hormone therapy is not medically indicated.

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


Answer: A 54-year-old male enrollee has requested a motorized wheelchair (power-operated vehicle) for treatment of his idiopathic transverse myelitis, suspected multiple sclerosis.

Answer: The power mobility device form signed by the patients primary care physician

Answer: endorses that the patient has sufficient upper limb function to propel an optimally configured manual wheelchair in the home through the course of a typical day.

Context: A 54-year-old male enrollee has requested a motorized wheelchair (power-operated vehicle) for treatment of his idiopathic transverse myelitis, suspected multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation does not substantiate the presence of impairments that would preclude the patient from accomplishing his mobility-related activities of daily living within the home with the aid of a manual wheelchair.  The records do not document any neurological or musculoskeletal impairment or pathology affecting the upper limbs.  He does not have a documented cardiovascular or pulmonary condition that is severe enough to preclude the use of a manual wheelchair to accomplish his mobility-related activities of daily living.  The power mobility device form signed by the patients primary care physician on the said date specifically endorses that the patient has sufficient upper limb function to propel an optimally configured manual wheelchair in the home through the course of a typical day.  With respect to falls, there is no evidence in the present case that would support that there would be a significant additional risk of falling when comparing a manual versus a power wheelchair.  All told, the requested motorized wheelchair (power-operated vehicle) is not medically necessary this patient.

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


Answer: A 44-year-old male enrollee has requested a DelRoyal T600 Digital hot/cold therapy system with blanket for treatment of his vertebral fractures.

Answer: the patient was prescribed the DeRoyal T600 Digital hot/cold therapy system with blanket for treatment of his low back pain.

Context: A 44-year-old male enrollee has requested a DelRoyal T600 Digital hot/cold therapy system with blanket for treatment of his vertebral fractures. Findings:  Three physician reviewers found that the patient was prescribed the DeRoyal T600 Digital hot/cold therapy system with blanket for treatment of his low back pain. A literature search revealed no studies demonstrating or even assessing the efficacy of a heating/cooling system for the treatment of low back pain. As such, this therapy should be considered experimental at this time absent additional clinical trials demonstrating the equivalence or superiority of the device when compared to standard alternatives.

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


Answer: A 25-year-old female enrollee has requested an MRI of the whole body, leg or foot for evaluation of her foot pain.

Answer: with the exception of x-rays, imaging has not been done.

Answer: This patient has a history of a foot neuroma.

Context: A 25-year-old female enrollee has requested an MRI of the whole body, leg or foot for evaluation of her foot pain. Findings:  The physician reviewer found that with the exception of x-rays, imaging has not been done.  Whole body MRI is not medically indicated for this patient since there is no history of malignancy. Whole body MRI, although not widely available, is generally reserved for the detection of skeletal metastases as well as other organ involvement.  This patient has a history of a foot neuroma.  Due to the fact that imaging of her feet has not been done despite symptoms which have persisted for over one year, bilateral MRI of the feet is medically indicated for the evaluation of this patient.  All told, in this patients case, evaluation with bilateral MRI of the feet is medically appropriate given her symptoms.

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


Answer: A 23-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of his medical condition.

Answer: this patient

Answer: exhibited suicidal ideation throughout his stay and lacked a strong support system outside the hospital setting.

Context: A 23-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of his medical condition.  Findings:  The physician reviewer found that this patient clearly exhibited suicidal ideation throughout his stay and lacked a strong support system outside the hospital setting.  The inpatient hospitalization was consistent with standards of medical practice in the community and his care could not be provided safely on an outpatient basis. Inpatient hospitalization was therefore medically necessary for this patient.

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


Answer: A 48-year-old female enrollee has requested iron infusions for treatment of her chronic anemia.

Answer: The patient has a serum ferritin from last year of 13 ng/mL

Answer: her blood work from this year shows low iron saturation values which are low in the single digits

Context: A 48-year-old female enrollee has requested iron infusions for treatment of her chronic anemia. Findings:  The physician reviewer found that this patients records are devoid of any current clinic notes which document anemia with an etiology of iron deficiency. Further, there is inadequate documentation of the patients failure to improve her iron stores with oral supplementation. The patient has a serum ferritin from last year of 13 ng/mL, which is low and suggestive of iron deficiency. More recently, her blood work from this year shows low iron saturation values which are low in the single digits and again suggestive of iron deficiency. However, the records do not clearly justify treatment at this time since there is insufficient documentation of an anemia work up or failure of oral supplements. In addition, the patients recent hemoglobin has not been provided for review. For these reasons, the requested therapy has not been demonstrated to be medically necessary for management of this patients condition.

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


Answer: The parent of a 7-year-old male enrollee has requested 25 hours of applied behavioral analysis therapy per week for treatment of the enrollees autism.

Context: The parent of a 7-year-old male enrollee has requested 25 hours of applied behavioral analysis therapy per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that upon reviewing the medical literature, there are numerous studies addressing the functional benefits of ABA therapy. When ABA therapy was first initiated, some providers recommended that 40 hours per week was indicated but this was later reduced to 20 hours per week as a result of the burden of the intensity that the therapy puts on families and service providers. Since that time, additional studies have been conducted looking at low intensity (less than 20 hours per week) and high intensity (more than 20 hours per week) to further assess the outcome relative to additional hours of treatment. In addition, studies have been conducted to address the need for intensive behavior therapy versus standardized care. Overall, the scientific data is supportive of the utility of behavioral therapy and suggest that patients who receive this treatment show a statistical improvement in cognitive, language and adaptive behavior skills when compared to patients who were untreated. However, Spreckley and Boyds meta analysis of the literature found that appropriately powered clinical trials with broader outcomes are still needed to fully establish the role of ABA in managing young patients with ASD. The authors cited a study by Roberts, et al. which determined that for best results, a minimum of 20 hours per week of intervention over 2 years, taking into account of each patients strengths and weaknesses and family circumstances, is essential for young patients with ASD to make gainsWhile there is no literature specifically addressing the utility of 25 hours per week of ABA therapy, there is support for high intensity therapy of at least 20 hours per week. Therefore, based on the clinical documentation provided as well as review of the relevant scientific evidence, there is adequate support for 20 hours of ABA therapy per week for this patient.

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


Answer: A 56-year-old female enrollee has requested radiofrequency ablation/neurolysis of the sacroiliac joint and lumbar spine (including CPT codes 64622 and 64640) for treatment of her degenerative disc disease and sacroiliac joint dysfunction.

Answer: this patient reported significant pain relief from the right sacroiliac (SI) joint injection

Answer: this patient reported 100% pain relief with the SI joint injection and 50% or more relief at 6-week follow-up

Context: A 56-year-old female enrollee has requested radiofrequency ablation/neurolysis of the sacroiliac joint and lumbar spine (including CPT codes 64622 and 64640) for treatment of her degenerative disc disease and sacroiliac joint dysfunction.  Findings:  Three physician reviewers found that this patient reported significant pain relief from the right sacroiliac (SI) joint injection, which is a clinical indication that she will benefit from the requested procedures. The available peer reviewed medical literature suggests that radiofrequency (RF) ablation of the SI joint is no longer investigational. Further, Ferrante and colleagues concluded that RF denervation has been shown to be efficacious for about six months of pain relief when used in patients with a successful SI joint injection. As this patient reported 100% pain relief with the SI joint injection and 50% or more relief at 6-week follow-up, she is an appropriate candidate for the proposed treatment.

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


Answer: A 60-year-old female enrollee has requested for chiropractic treatments for treatment of her cervical spondylosis and brachial neuritis.

Context: A 60-year-old female enrollee has requested for chiropractic treatments for treatment of her cervical spondylosis and brachial neuritis.  Findings:  The physician reviewer found that the literature supports the effectiveness of manual therapy and spinal manipulative therapy for the management of chronic neck pain (Hurwitz, et al.). In addition, Wolsko and colleagues concluded that chiropractic techniques are commonly applied for the treatment of neck pain, and have been rated very helpful by patients. Moreover, Bronfort and colleagues reported positive outcomes with spinal manipulative therapy and mobilization for the management of low back pain.

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


Answer: The parent of a 14-year-old male enrollee has requested growth hormone (GH) therapy (Nutropin AQ) for the treatment of the enrollees growth hormone deficiency.

Answer: the patients endocrinologists letter indicates an annual growth velocity of 1.2 cm

Answer: The stimulation testing showed subnormal GH responses. The records indicate the patient is overweight.

Context: The parent of a 14-year-old male enrollee has requested growth hormone (GH) therapy (Nutropin AQ) for the treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that this patients projected adult height could approximate six feet according to the Greulich and Pyle Hand Atlas Table. However, the patients endocrinologists letter indicates an annual growth velocity of 1.2 cm, which is subnormal. The stimulation testing showed subnormal GH responses. The records indicate the patient is overweight. Relative obesity is also associated with blunted GH responses, especially in a patient who is insulin-resistant. Based on the evidence provided, this is a patient who has markedly delayed puberty who appears to be destined to reach a normal adult height (given the heights of his parents). The objective documentation does not does not provide confirmatory evidence of the stated low growth rate of 1.2 cm per year. In this case, there is no documented evidence over time of an abnormally low growth rate; a valid growth rate requires height measurements of six to twelve months in duration, and not over a lesser period of time. The submitted records in this patients case do not support the medical necessity of Nutropin AQ.

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


Answer: The parent of a 15-year-old male enrollee has requested for subtalar arthroereisis surgery for treatment of the enrollees bilateral pes planus.

Context: The parent of a 15-year-old male enrollee has requested for subtalar arthroereisis surgery for treatment of the enrollees bilateral pes planus. Findings:  Two physician reviewers found that Subtalar arthroereisis has proven efficacy in the treatment of pediatric flatfoot with overpronation syndrome. One of the major benefits of the procedure is that it is minimally invasive and reversible. A study by Forg and colleagues reported on the use of the Smith subtalar arthroereisis implant (STA-peg) to correct severe collapsing pes valgoplanus in children. Twenty-one patients with a total of 40 STA-peg procedures were evaluated subjectively and objectively. The average age at the time of surgery was 9.7 years (4 to 16 years). The follow-up period averaged 36 months (12 to 90 months). The authors concluded that subjective, objective, and radiographic results were positive and the complication rate was low.

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


Answer: A 59-year-old female enrollee has requested cervical discography for evaluation of her neck pain and headaches.

Context: A 59-year-old female enrollee has requested cervical discography for evaluation of her neck pain and headaches. Findings:  Three physician reviewers found that the medical literature indicates that cervical discography is of equivocal help in terms of identifying a pain generator and predicting results from surgery. However, in this case, the patients history of chronic neck pain as well as associated fibromyalgia and multilevel degenerative findings on MRI are key factors. Regardless of the outcome of the multilevel discogram, this patient would be a poor candidate for cervical surgery.  Confirming a pain generator is particularly challenging given the comorbid diagnoses of fibromyalgia and chronic pain. For these reasons, the medical literature does not demonstrate that discography was indicated in this case, as it would not have been likely to alter the treatment plan

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


Answer: A 59-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his recurrent prostate cancer.

Context: A 59-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his recurrent prostate cancer. Findings:  The physician reviewer found that the medical literature does not support the clinical benefit of the administration of radiation to grossly positive lymph node metastatic disease after treatment with chemotherapy and hormone ablation. Radiation, specifically IMRT, for the treatment of metastatic adenocarcinoma in retroperitoneal lymph nodes is of unproven efficacy and not medically necessary in this setting. The standard of care remains chemotherapy or hormone ablation. For this patient, with metastatic disease, the requested local treatment is not likely to provide positive results and remains unproven in the medical literature.

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


Answer: A 43-year-old female enrollee has requested bariatric surgery including laparoscopic banding and revision of previous gastric restrictive procedure for the treatment of her morbid obesity.

Context: A 43-year-old female enrollee has requested bariatric surgery including laparoscopic banding and revision of previous gastric restrictive procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patients records do not document a complication of the Roux-en-Y gastric bypass procedure. In addition, the patient admits to emotional eating since the Roux-en-Y procedure and a laparoscopic gastric band placed over the bypass will not necessarily prevent such cravings. Given the patients small pouch and lack of documented follow-up, aggressive dietary and behavioral counseling with exercise would be the next appropriate step in this setting. At this time, there is a paucity of studies regarding the long-term (greater than two years) outcome of patients who have undergone revision of previous gastric bypass. Thus, the proposed procedure remains of questionable efficacy and is indicated to remedy an anatomical failure of the previous surgery. In this case, anatomical failure is not demonstrated by the records provided.

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


Answer: A 59-year-old female enrollee has requested a follow-up visit with her gastroenterologist for the treatment of her chronic hepatitis B.

Answer: This patient has chronic, active hepatitis B and is being treated with entecavir. Her hepatitis B viral load was negative in April 2009.

Context: A 59-year-old female enrollee has requested a follow-up visit with her gastroenterologist for the treatment of her chronic hepatitis B. Findings:  The physician reviewer found that This patient has chronic, active hepatitis B and is being treated with entecavir. Her hepatitis B viral load was negative in April 2009. Most primary care physicians are not familiar with the guidelines for the treatment of hepatitis B. The expertise and experience of gastroenterologists and hepatologists are needed for monitoring patients with hepatitis B. These specialists are familiar with antiviral therapy for hepatitis B, including the efficacy, resistance profile and stopping rules. These specialists also have the required expertise for monitoring for viral breakthrough and surveillance for hepatocellular carcinoma. Follow-up care with the patients gastroenterologist is medically appropriate and indicated.

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


Answer: A 28-year-old male enrollee has requested substance abuse inpatient care and acute detoxification for the treatment of his polysubstance dependence.

Answer: the patient had received five days of detoxification services. By the end of the period at issue, the patient reported feeling physical improvement.

Context: A 28-year-old male enrollee has requested substance abuse inpatient care and acute detoxification for the treatment of his polysubstance dependence. Findings:  The physician reviewer found that the submitted clinical documentation does not demonstrate the medical necessity for continued acute inpatient/detoxification treatment. There is no report of a physical examination or vital signs documenting that the patient was unstable from a medical standpoint as of the last authorized date of service. In addition, although the records provide limited details regarding the detoxification protocol, it appears the patient had received five days of detoxification services. By the end of the period at issue, the patient reported feeling physical improvement. Thus, the submitted evidence does not establish that the patient was experiencing significant withdrawal symptoms during the period in question such that continued acute inpatient/detoxification services were required.

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


Answer: A 58-year-old female has requested speech therapy for the treatment of her habit cough.

Answer: this patient has a chronic cough that had failed to be diagnosed and treated through prior extensive evaluation.

Answer: her main complaint is the chronic cough

Answer: Endoscopy showed significant plica ventricularis

Context: A 58-year-old female has requested speech therapy for the treatment of her habit cough. Findings:  The physician reviewer found that this patient has a chronic cough that had failed to be diagnosed and treated through prior extensive evaluation. Although her main complaint is the chronic cough, her history and examination show evidence of vocal straining with use of the false cords for phonation. Endoscopy showed significant plica ventricularis, which is a laryngeal function disorder caused by phonation of the ventricular folds (false folds) rather than the true vocal folds. The patients condition traditionally is responsive to speech therapy.  Given the patients laryngeal dysfunction, speech therapy is medically indicated and appropriate.

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


Answer: A 19-year-old female enrollee has requested acute inpatient psychiatric treatment for the treatment of her behavioral health problems.

Answer: during her stay, several psychotropic medication adjustments were required.

Answer: she was also highly anxious with nightmares and insomnia.

Context: A 19-year-old female enrollee has requested acute inpatient psychiatric treatment for the treatment of her behavioral health problems. Findings:  The physician reviewer found that during her stay, several psychotropic medication adjustments were required. The overall medical documentation supports the level of care provided. The patient remained at risk for self harm, she was also highly anxious with nightmares and insomnia. The services provided are consistent with the recommendations of the American Psychiatric Association (APA), the level of care guidelines published by the American Academy of Child and Adolescent Psychiatry (AACAP) and the Association of Community Psychiatrists.

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


Answer: A 60-year-old female enrollee has requested for use of a real time heart monitor for evaluation of her atrial fibrillation.

Context: A 60-year-old female enrollee has requested for use of a real time heart monitor for evaluation of her atrial fibrillation.  Findings:  Three physician reviewers found that guidelines from the American College of Cardiology (ACC) in 2006 regarding the recommended treatment of PAF. The decision to anticoagulate the patient with aspirin versus Coumadin is typically made by assessing her risk factors such as age, valvular disease or CAD. Real time telemetry has not been shown to change the assessment of the need for anticoagulation. Electrocardiogram monitoring has been recommended in the assessment episodes of asymptomatic PAF or to judge the adequacy of rate control. However, the guidelines do not, as of yet, recommend a real time component to the monitoring. Prolonged or frequent monitoring may be necessary to reveal episodes of asymptomatic atrial fibrillation (AF), which may be a cause of cryptogenic stroke. Ambulatory ECG (i.e., Holter) monitoring is also useful to judge the adequacy of rate control. This technology may provide valuable information to guide drug dosage for rate control or rhythm management.

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


Answer: A 64-year-old female enrollee has requested therapeutic activities for the treatment of her low back pain.

Context: A 64-year-old female enrollee has requested therapeutic activities for the treatment of her low back pain. Findings:  The physician reviewer found that there is insufficient evidence in the literature to support the benefit of the prescribed program of computer-assisted exercise over standard physical therapy for chronic low back pain. In contrast, standard physical therapy including strengthening and stretching exercise, modalities, and transition to a home exercise program is more consistent with standard clinical practice, and as the literature suggests, may result in greater improvement in symptoms. The evidence does not demonstrate that computer-assisted exercise results in any added benefit over standard physical therapy for the treatment of low back pain.

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


Answer: The parent of an eight-year-old male enrollee has requested speech therapy for the treatment of the enrollees Aspergers disorder.

Answer: A formal assessment noted that the patient had a normal voice, good fluency and articulation with low average to borderline expressive and receptive language skills.

Context: The parent of an eight-year-old male enrollee has requested speech therapy for the treatment of the enrollees Aspergers disorder. Findings:  The physician reviewer found that the medical documentation indicates that the patients language development appears normal. A formal assessment noted that the patient had a normal voice, good fluency and articulation with low average to borderline expressive and receptive language skills. The submitted clinical documentation does not demonstrate that the patient had deficits in speech and language which necessitated speech therapy.

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


Answer: The parent of a 5-year-old male enrollee has requested  for an ultra-light wheelchair for treatment of his cerebral palsy.

Context: The parent of a 5-year-old male enrollee has requested  for an ultra-light wheelchair for treatment of his cerebral palsy. Findings:  The physician reviewer found that this non-ambulatory patient will likely remain non-ambulatory and will require supportive wheelchairs throughout his lifetime. The  literature also shows that transportation load is non-variable and a constant, nearly daily need for children with cerebral palsy. The literature also notes that transportation safety depends on adequate restraints and support which would require an ultra-light wheelchair to have the supportive system recommended by the patients physical therapist.

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


Answer: A 55-year-old female enrollee has requested for a spinal cord stimulator trial for treatment of her back and hip pain status post laminotomies and foraminotomies with nerve root and spinal canal decompression.

Context: A 55-year-old female enrollee has requested for a spinal cord stimulator trial for treatment of her back and hip pain status post laminotomies and foraminotomies with nerve root and spinal canal decompression.  Findings:  Two physician reviewers found that the proportion of patients with intractable pain successfully managed with spinal cord stimulation (SCS) remains disputed. They analyzed 27 consecutive patients with intractable pain treated with SCS using identical hardware (Itrel II System) by a single satisfactory diagnosis. A rigid selection protocol was used including: 1) satisfactory diagnosis of the pathologic process resulting in pain; 2) corrective surgical procedure was judged not feasible by surgeons experienced in the particular pathology, (i.e., vascular peripheral nerve, spine); 3) lack of satisfactory response to non-interventional pain management modalities by an interdisciplinary pain clinic; and 4) independent psychological evaluation, including a structured interview was performed by a psychologist specializing in chronic pain management. In the last eight cases, a battery of self-report tests designed to assess psychosocial and behavioral consequences of the chronic pain problem were administered as well. All cases were of nonmalignant pain, except for one patient. Thirteen cases were diagnosed with failed back surgery syndrome (FBSS), one older patient with lumbosacral radiculopathy who refused decompression, one patient with cervical radiculopathy and Klippel-Feil syndrome, six with reflex sympathetic dystrophy (RSD), two with peripheral vascular ischemic disease, one with post-thoracotomy pain syndrome, one with leg pain following resection of angiolipoma, one with traumatic superficial peroneal neuropathy, and one with Pancoast's tumor. All patients underwent a three day trial screening with Pisces-Quad/Resume epidural leads connected to a temporary external stimulator. An Itrel II System pulse-generator was internalized in each of the 24 patients who had successful trials (3 cervical and 21 thoracic-lumbar). There was no morbidity. Pain reduction was sustained in 22 out of the 24 patients who continued to use the stimulator. The same number would choose to receive an electrical stimulator again. Normalization or improvement in Quantitative Sudomotor Axon Reflex Test (Q-SART) and Thermography were documented in the patients with RSD. They concluded that rigid selection protocol can maximize the proportion of patients with intractable pain who are successfully treated with SCS. Strict neurosurgical technique eliminates infection risk. Hardware selection minimizes incidence of malfunction.

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


Answer: A 64-year-old female enrollee has requested bilateral mastopexy for the treatment of her bilateral breast ptosis.

Answer: The plastic surgeons consultation note describes problems with intertrigo

Answer: The patient has been treated by a chiropractor

Context: A 64-year-old female enrollee has requested bilateral mastopexy for the treatment of her bilateral breast ptosis. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the proposed procedure is reconstructive in nature. While the patient has evidence of breast ptosis, this is a natural consequence of weight loss and aging. There is no evidence that the ptosis is secondary to macromastia. As such, the patient does not have an abnormal structure of the body. In the absence of evidence of an abnormal structure of the body caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease, the proposed procedure does not meet the definition of reconstructive surgery as defined by California law. Concerning general concepts of medical necessity, this patient has the typical complaints for symptomatic macromastia, but she does not have large breasts. Symptomatic macromastia is a mechanical problem due to the pulling forces exerted by heavy breasts on the musculoskeletal system. Based on her photographs, this patient does not have heavy breasts. Rather, she has involutional ptosis from her weight loss. Although the efficacy of breast weight reduction as a treatment for musculoskeletal strain is well-established, the medical literature provides no evidence that correction of breast ptosis without a reduction of breast weight is an effective treatment for musculoskeletal pain. The plastic surgeons consultation note describes problems with intertrigo, but the medical records do not provide any documentation in the form of primary care physician or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either never responded to topical therapy given or, despite initial response, have recurred and caused significant functional impairment. Likewise, the records do not include any office notes that document long-standing musculoskeletal symptoms that have failed to respond to conservative treatments. The patient has been treated by a chiropractor, but office notes are not submitted that document the indications and response to treatment. Irrespective of whether the patient has musculoskeletal symptoms, there is no scientific evidence that the proposed treatment will be effective for her complaints. Bilateral mastopexy is not medically necessary for this patient.

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


Answer: A 59-year-old male enrollee has requested chemoembolization for the treatment of his liver cancer.

Context: A 59-year-old male enrollee has requested chemoembolization for the treatment of his liver cancer. Findings:  The physician reviewer found that chemoembolization is considered a relatively standard treatment for unresectable hepatocellular carcinoma and is endorsed by National Comprehensive Cancer Network Guidelines. Chemoembolization is not curative in this setting, but is used to improve disease control. Typically, if both lobes are involved, the lobes will be treated sequentially. Based upon the evidence provided, the patient was an appropriate candidate for the therapy and its use in this setting was clinically indicated.

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


Answer: A 57-year-old female enrollee has requested acute hospital services for the treatment of her nonunion of left distal radius with retained hardware.

Answer: the patients physician has reported concern regarding the patients level of pain given her history of reflex sympathetic dystrophy. The physician recommended a second day of hospitalization, and the patient complied with this recommendation.

Context: A 57-year-old female enrollee has requested acute hospital services for the treatment of her nonunion of left distal radius with retained hardware. Findings:  The physician reviewer found that the patients physician has reported concern regarding the patients level of pain given her history of reflex sympathetic dystrophy. The physician recommended a second day of hospitalization, and the patient complied with this recommendation. It was imperative that pain relief was adequate after the patients nerve block wore out and prior to discharge. The acute hospital stay services provided on the dates in question were medically indicated and appropriate for this patients postoperative care.

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