Answer: A 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain.

Answer: She has had at least 75 percent reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular SIJ injection on two separate occasions.

Answer: the postoperative CT scan on 11/5/15 shows no ongoing neural compression and no central canal or foraminal stenosis on the postoperative CT scan.

Context:
Summary Reviewer 2

A 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain. The physician reviewer found that the North American Spine Societys recommendations include that percutaneous sacroiliac joint fusion should only be considered when all inclusion criteria have been met. The authors state that due to the relatively moderate evidence, it is particularly critical that inclusion criteria are scrutinized and patient selection is executed with vigilance. In this case the patient meets North American Spine Society criteria for the proposed sacroiliac joint fusion. She has had at least 75 percent reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular SIJ injection on two separate occasions. In addition, the postoperative CT scan on 11/5/15 shows no ongoing neural compression and no central canal or foraminal stenosis on the postoperative CT scan. This patient meets all NASS criteria for the proposed surgery. For these reasons, sacroiliac joint fusion surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: A 55-year-old female enrollee has requested authorization and coverage for botulinum toxin type A (Botox) treatment and ongoing treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.

Answer: the patient presents with a long history of migraine headaches dating to childhood. The records indicate that before starting Botox she had a baseline headache frequency of 16 to 24 per month

Answer: the patient has had a marked improvement documented with Botox treatments for more than 10 years.

Context:
Summary Reviewer 2
A 55-year-old female enrollee has requested authorization and coverage for botulinum toxin type A (Botox) treatment and ongoing treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that ongoing Botox treatment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient presents with a long history of migraine headaches dating to childhood. The records indicate that before starting Botox she had a baseline headache frequency of 16 to 24 per month, which is consistent with the diagnosis of chronic migraine. In addition, the patient has had a marked improvement documented with Botox treatments for more than 10 years. In sum, Botox treatment for chronic migraine is indicated for this patient and ongoing treatments are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: The patient is a 47-year-old female who has requested authorization and coverage for Neulasta. She underwent chemotherapy for breast cancer. The patient has requested authorization and coverage for Neulasta. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient.

Context:
Summary Reviewer

The patient is a 47-year-old female who has requested authorization and coverage for Neulasta. She underwent chemotherapy for breast cancer. The patient has requested authorization and coverage for Neulasta. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. Neulasta has been approved by the U.S. Food and Drug Administration to decrease the incidence of infection (as manifested by febrile neutropenia) in patients with non-myeloid malignancies receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile neutropenia. The combination of Adriamycin and cyclophosphamide carries a high risk of neutropenic fever. The standard of care is administration in a dose dense fashion every two weeks with growth factor support with Neulasta. Therefore, Neulasta is medically necessary for the treatment of this patient.

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


Answer: A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.

Answer: this patient had a recent transient ischemic attack while flying on an airplane. He was evaluated and has no other reason for transient ischemic attack other than the patent foramen ovale.

Context:
Summary Reviewer 1

A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient had a recent transient ischemic attack while flying on an airplane. He was evaluated and has no other reason for transient ischemic attack other than the patent foramen ovale. In addition, the development of the transient ischemic attack symptoms while flying a high altitude makes the patent foramen ovale an even more likely etiology of the symptoms as right heart pressures increase at high altitudes, and the risk of transient deep vein thrombosis is higher as well. This combination (occult deep vein thrombosis with elevated right heart pressures because of lower air pressures) makes the likelihood of paradoxical embolism from increased right to left shunting significantly higher in the setting of a large patent foramen ovale. This adds further credence to the clinical suspicion of the patent foramen ovale being the culprit pathology of the transient ischemic attack in this case. Recent data and meta-analyses suggest that patent foramen ovale closure prevents recurrent crytogenic stroke better than medical therapy alone in patients with no other suspected cause of the stroke and likely transient ischemic attacks as well. Therefore, patent foramen ovale closure is likely to be more beneficial than any available standard therapy.

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


Answer: A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.

Answer: this patient presented with a transient ischemic attack in the setting of reported hypertensive urgency. There are no other verified transient ischemic attacks and a reportedly normal head computed tomography (CT) scan.

Context:
Summary Reviewer 2

A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presented with a transient ischemic attack in the setting of reported hypertensive urgency. There are no other verified transient ischemic attacks and a reportedly normal head computed tomography (CT) scan. In patients with transient ischemic attacks and patent foramen ovales, transcatheter closure has been demonstrated to be of mild benefit only in younger patients without another potential source of transient ischemic attack, such as hypertensive urgency, and mainly in patients with transient ischemic attacks despite antiplatelet medication. This patient does not fit those criteria since there is another potential source and his age is greater than 60. In sum, patent foramen ovale closure is not likely to be more beneficial than any available standard therapy.

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


Answer: A 56-year-old male enrollee has requested authorization and coverage for uvulopalatopharyngoplasty for obstructive sleep apnea.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.

Answer: This patient has mild obstructive sleep apnea and snoring.  It is noted that his obstructive sleep apnea is severe when in the supine position.

Context:
Summary Reviewer

A 56-year-old male enrollee has requested authorization and coverage for uvulopalatopharyngoplasty for obstructive sleep apnea.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has mild obstructive sleep apnea and snoring.  It is noted that his obstructive sleep apnea is severe when in the supine position.  There is no documentation of retropalatal obstruction or of redundant palatal soft tissue.  While uvulopalatopharyngoplasty is a common surgical procedure for treatment of obstructive sleep apnea, its success rate as a stand-alone surgery is low.  Its success rate in conjunction with nasal surgery is not much greater.  The fact that apnea-hypopnea index is greater when in the supine position does not determine that there is retropalatal airway obstruction.  All told, the requested uvulopalatopharyngoplasty is not medically indicated for the treatment of this patient.  Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

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


Answer: A 54-year-old female enrollee has requested reimbursement for inpatient hospitalization provided from 3/31/17 through 4/07/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who sustained injuries when she fell off a horse.

Answer: this patient presented status post a traumatic fall from a horse resulting in severe back pain. Clinical examination findings were consistent with imaging evidence of L1 and L3 acute compression fractures. She had severe pain that was not controlled with oral medications. She was admitted for inpatient care for pain control and observation on 3/31/17. She was placed on bed rest with bracing ordered. She continued to require intravenous medication due to inadequate relief with oral medications. She was very limited in her activity due to severe pain. Given the failure of closed treatment with bracing and continued severe pain with associated functional limitations, she underwent L1 and L3 vertebroplasty on 4/04/17. Following this procedure, she was able to ambulate with physical therapy, and oral pain medications provided adequate control as of 4/07/17. She was discharged to home on 4/07/17 with home health services.

Context:
Summary Reviewer

A 54-year-old female enrollee has requested reimbursement for inpatient hospitalization provided from 3/31/17 through 4/07/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who sustained injuries when she fell off a horse. The physician reviewer found that this patient presented status post a traumatic fall from a horse resulting in severe back pain. Clinical examination findings were consistent with imaging evidence of L1 and L3 acute compression fractures. She had severe pain that was not controlled with oral medications. She was admitted for inpatient care for pain control and observation on 3/31/17. She was placed on bed rest with bracing ordered. She continued to require intravenous medication due to inadequate relief with oral medications. She was very limited in her activity due to severe pain. Given the failure of closed treatment with bracing and continued severe pain with associated functional limitations, she underwent L1 and L3 vertebroplasty on 4/04/17. Following this procedure, she was able to ambulate with physical therapy, and oral pain medications provided adequate control as of 4/07/17. She was discharged to home on 4/07/17 with home health services. Evidence-based medical guidelines support hospitalization for parental narcotics and inability to manage basic activities of daily living at home, and additionally support a three-day best practice length of stay following vertebroplasty. Continued inpatient stay is supported until acceptable patient status for the next level of care is achieved, including pain is adequately managed on oral medications, and activity levels are at baseline or acceptable. Therefore, inpatient hospitalization provided from 3/31/17 through 4/07/17 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

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


Answer: A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis.

Answer: In this patients case, she had a recent colonoscopy showing endoscopic healing, and she had no complaints relative to her colitis.

Context:
Summary Reviewer 1

A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis. The physician reviewer found that Calprotectin is a zinc and calcium binding protein that is derived mostly from neutrophils and monocytes. It can be detected in tissue samples, body fluids, and stools, making it a potentially valuable marker of neutrophil activity. Fecal calprotectin levels are increased in intestinal inflammation and may be useful for distinguishing inflammatory from noninflammatory causes of chronic diarrhea. An additional potential role of fecal calprotectin is in the monitoring of patients with colitis to predict whether they are going to have a disease flare and to distinguish in symptomatic patients whether the symptoms are due to inflammation or to functional disease. In this patients case, she had a recent colonoscopy showing endoscopic healing, and she had no complaints relative to her colitis. There is a lack of support for the services at issue in this setting. Thus, fecal calprotectin testing performed on 11/22/17 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis.

Answer: In this patients case, the test allowed for assessment of ulcerative colitis disease activity without colonoscopy.

Context:
Summary Reviewer 3

A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis. The physician reviewer found that the use of fecal calprotectin is supported for management of patients with ulcerative colitis to prevent invasive interventions such as colonoscopy. A randomized, prospective, controlled trial by Lasson and colleagues evaluating patients with ulcerative colitis showed lower relapse rate than control when using calprotectin to direct management with medications. Another prospective study by Costa and colleagues showed that unlike in Crohns disease, fecal calprotectin was sensitive and specific for prediction of relapse in ulcerative colitis, making it a useful tool for non-invasive monitoring. In this patients case, the test allowed for assessment of ulcerative colitis disease activity without colonoscopy. For these reasons, fecal calprotectin testing performed on 11/22/17 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: The patient is a 30-year-old female with moderate-severe rheumatoid arthritis. The patient has requested authorization and coverage for Enbrel SureClick. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient.

Answer: In this case, the records document a history of moderate-severe rheumatoid arthritis. In addition, she has failed DMARD therapy. She previously was treated with methotrexate, sulfasalazine and hydroxychloroquine, with uncontrolled disease.

Answer: She was placed on the TNFi, Humira, which was ineffective. She was then placed on an alternate TNFi, Enbrel SureClick. On 7/29/20, office visit notes indicate that Enbrel SureClick was helping to control rheumatoid arthritis.

Context:
Summary Reviewer

The patient is a 30-year-old female with moderate-severe rheumatoid arthritis. The patient has requested authorization and coverage for Enbrel SureClick. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that according to the 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, in established rheumatoid arthritis, aIf disease activity remains moderate or high despite DMARD monotherapy, the recommendation is to use combination traditional DMARDs or add a tumor necrosis factor inhibitor (TNFi) or a non-TNF biologic or tofacitinib (all choices with or without methotrexate, in no particular order of preference), rather than continuing DMARD monotherapy alone.a In this case, the records document a history of moderate-severe rheumatoid arthritis. In addition, she has failed DMARD therapy. She previously was treated with methotrexate, sulfasalazine and hydroxychloroquine, with uncontrolled disease. It is therefore appropriate to consider TNFi therapy in this case based on the guidelines. She was placed on the TNFi, Humira, which was ineffective. She was then placed on an alternate TNFi, Enbrel SureClick. On 7/29/20, office visit notes indicate that Enbrel SureClick was helping to control rheumatoid arthritis. There is sufficient support for the requested medication in this clinical setting. Therefore, Enbrel SureClick is medically necessary for the treatment of this patient.

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


Answer: A 43-year-old female enrollee has requested reimbursement for the blood testing provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cardiovascular risk.

Context:
Summary Reviewer 2

A 43-year-old female enrollee has requested reimbursement for the blood testing provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cardiovascular risk. The physician reviewer found that the use of the advanced lipoprotein testing with measurement of low density lipoprotein (LDL) cholesterol particle numbers remains controversial. While some providers have advocated for its use, the American College of Cardiology (ACC) guidelines do not support its use, recommending instead standard risk assessment protocols and standard lipid profile testing (Stone, et al). The ACC moved away from specific target goals of LDL in their most recent guidelines, based on review of outcome studies. Lloyd-Jones and colleagues provided an expert consensus update from the ACC and it does not mention the use of advanced lipid testing. Overall, the guidelines do not establish a strong recommendation for use of the advanced lipid profiles at this time. Thus, the blood testing provided on 1/17/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer:
A 24-year-old female enrollee has requested authorization and coverage for lower esophageal
myotomy, transoral (peroral endoscopic myotomy) (POEM) and one inpatient day. The Health
Plan has denied this request indicating that the requested service is investigational for the
treatment of the enrollees medical condition.

Context:
Summary Reviewer 1

A 24-year-old female enrollee has requested authorization and coverage for lower esophageal
myotomy, transoral (peroral endoscopic myotomy) (POEM) and one inpatient day. The Health
Plan has denied this request indicating that the requested service is investigational for the
treatment of the enrollees medical condition. The physician reviewer found  that there is
sufficient  support  for  the  requested  service  in  this  clinical  setting.  The  American
Gastroenterological Association best-practice guideline states that if the expertise is available,
POEM should be considered as treatment option comparable with laparoscopic Heller myotomy
for any of the achalasia syndromes. The American Society for Gastrointestinal Endoscopy has
recently published a statement based on available evidence, stating that POEM is a potential
attractive option for the treatment of achalasia that offers a minimally invasive endoscopic
approach to myotomy with the potential for a durable response to therapy. Clinical studies and
trials  have  shown  comparable  efficacy  with  surgery  when  expertise  in  POEM  is  available.
However,  despite  comparable  efficacy,  POEM  is  significantly  less  invasive  than  surgical
intervention, resulting in less postoperative pain and a more rapid recovery. In this patient with
symptoms including dysphagia and regurgitation, as well as failure of pneumatic dilation, the use
of POEM is supported by current medical literature and guidelines. Therefore, lower esophageal
myotomy, transoral POEM and one inpatient day is likely to be more beneficial than any available
standard therapy.

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


Answer: A 60-year-old female enrollee has requested authorization and coverage for Xifaxan 500 mg. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition.

Answer: the patient had small intestinal bacterial overgrowth.

Context:
Summary Reviewer

A 60-year-old female enrollee has requested authorization and coverage for Xifaxan 500 mg. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the patient had small intestinal bacterial overgrowth. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. The medication has been shown to have greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. Results are sustained for several weeks after treatment. Moraru and colleagues performed a prospective trial of patients with irritable bowel syndrome and small intestinal bacterial overgrowth. The authors found that 86% responded to Xifaxan, and symptoms were reduced as well. Xifaxan is effective for the treatment of constipation-predominant irritable bowel syndrome. In this case, while antispasmodic medications may address irritable bowel syndrome, they would not be expected to improve small intestinal bacterial overgrowth. Anti-diarrheal medications would not be appropriate in the use of constipation. Therefore, the use of Xifaxan 550 mg three times daily for 14 days is supported as medically necessary for the treatment of this patients small intestinal bacterial overgrowth in the setting of irritable bowel syndrome.

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


Answer: A 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma.

Context:
Summary Reviewer 1

A 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma. The physician reviewer found that the DecisionDX is a study of 15 to 31 genes in a patients melanoma cells.  It has been used to classify the individuals melanoma as having either a high or low risk of metastasis.  It is controversial in cutaneous melanoma as to whether it has additional value when added to the usual pathologic prognostic factors.  However, it is particularly useful in the analysis of uveal melanoma and has been validated in several studies.  Specifically, a Class 1 category carries with it a less than 20% chance of metastasis, whereas Class 2 has a greater than 70% chance of metastasis.  This testing has become a standard in many ocular cancer centers.  Its clinical value lies in determining the need for intense surveillance, and possibly to assist in the decision as to adjuvant therapy.  Therefore, DecisionDX-UM assay performed on 5/09/16 was likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: A 67-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees bilateral sacroiliac joint pain status post revision lumbar surgery.

Answer: the patient has demonstrated continued pain that interferes with activities of daily living and results in functional disability

Context:
Summary Reviewer 1

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

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


Answer: A 52-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.

Context:
Summary Reviewer 1

A 52-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has been thought to add a bit to the statistics. DecisionDx-Melanoma gene expression testing is a study of 31 genes in the cells of an individuals melanoma. It then classifies the melanoma based on the five-year risk of metastases. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients having sentinel node biopsy. Berger reported on 156 cases, but there was not sufficient follow-up to determine the clinical value of the assay. It is not known how the five-year DecisionDx-Melanoma data compares and relates to the 10-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma class can be used to make clinical decisions. Therefore, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than other methods of evaluating this patient.

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


Answer: The patient is a 42-year-old female who has been treated for the following conditions: low back pain; other intervertebral disc degeneration, lumbosacral region; other intervertebral disc degeneration, lumbar region; radiculopathy, lumbar; other spondylosis, lumbar region; other intervertebral disc displacement, lumbar region. The patient has requested authorization and coverage for spinal surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.

Answer: she is noted to be a daily tobacco user and notes she will quit nicotine

Context:
Summary Reviewer

The patient is a 42-year-old female who has been treated for the following conditions: low back pain; other intervertebral disc degeneration, lumbosacral region; other intervertebral disc degeneration, lumbar region; radiculopathy, lumbar; other spondylosis, lumbar region; other intervertebral disc displacement, lumbar region. The patient has requested authorization and coverage for spinal surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.  The physician reviewer found that Bydon and colleagues noted, aA trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options may include physical therapy, epidural steroid injection, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion.a Chan and colleagues stated, aPatients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-selected patients who fail conservative management strategies, surgical management is appropriate.a  In this patientas case, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures prior to requested surgery to include (but not limited to) physical therapy measures. In addition, she is noted to be a daily tobacco user and notes she will quit nicotine; however, follow-up documentation does not indicate this has been completed. The provided imaging studies, including the dynamic x-rays from 8/10/21, do not corroborate movement/instability at the requested level, and detailed documentation is not evident regarding potential impending/inevitable temporary intraoperative instability. There is a lack of support for the requested services in this clinical setting. Therefore, the requested spinal surgery is not medically necessary 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 reimbursement for infliximab antibody testing performed on 3/30/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.

Context:
Summary Reviewer 2

A 36-year-old female enrollee has requested reimbursement for infliximab antibody testing performed on 3/30/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that management of ulcerative colitis using infliximab antibody testing has not been standardized, and recommendations for management based on test results (change to a different medication versus increase in dose) have not been formed (Kornbluth, et al). In addition, the use of infliximab antibody testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies (Adedokun, et al). Based on the clinical literature, the infliximab antibody testing performed on 3/30/15 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 53-year-old male enrollee has requested reimbursement for inpatient hospital stay from 12/20/16 through 12/24/16.  The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition.

Answer: In this case, the patient was admitted in stable condition with new onset atrial fibrillation

Answer: At the time of admission, the patient was afebrile with a normal white blood cell count and was hemodynamically stable without evidence of congestive heart failure.  On 12/22/16, the patient was noted to have worsening abdominal pain with a worsening leukocytosis and imaging consistent with acute cholecystitis.

Answer: the patient was at high risk for perioperative complications. Therefore, a cholecystostomy catheter was placed for drainage. In this case, the patients clinical course worsened.

Context:
Summary Reviewer

A 53-year-old male enrollee has requested reimbursement for inpatient hospital stay from 12/20/16 through 12/24/16.  The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue.  Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition with new onset atrial fibrillation and could have been treated at a lower level of care. At the time of admission, the patient was afebrile with a normal white blood cell count and was hemodynamically stable without evidence of congestive heart failure.  On 12/22/16, the patient was noted to have worsening abdominal pain with a worsening leukocytosis and imaging consistent with acute cholecystitis.  Given the patients recent arrhythmia and need for anticoagulation, the patient was at high risk for perioperative complications. Therefore, a cholecystostomy catheter was placed for drainage. In this case, the patients clinical course worsened.  Given the potential for cardiac complications, acute inpatient medical admission from 12/22/16 through 12/24/16 was medically necessary. However, inpatient hospital stay from 12/20/16 through 12/21/16 was not medically necessary for the treatment of this patient. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.

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


Answer: A 32-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 4/12/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition.

Context:
Summary Reviewer 3
A 32-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 4/12/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that polymerase chain reaction testing has been compared to traditional testing for vaginitis. The literature supports the use of polymerase chain reaction testing because it results in significantly higher sensitivity and negative predictive value than clinical diagnosis or clinical testing.  The test was also superior for detecting more than one cause for vaginitis. The medical evidence supports polymerase chain reaction testing as a means of accurate detection which allows for appropriate treatment. Therefore, polymerase chain reaction testing performed on 4/12/21 was likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.

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


Answer: A 61-year-old male enrollee has requested reimbursement for surgical services (atrial fibrillation ablation) performed on 7/10/13. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees recurrent symptomatic atrial fibrillation.

Answer: Based on the documentation submitted for review, the patient presented with symptomatic paroxysmal atrial fibrillation in spite of a prior remote ablation in 2011 and suppressive antiarrhythmic medication trials.

Context:
Summary Reviewer 2

A 61-year-old male enrollee has requested reimbursement for surgical services (atrial fibrillation ablation) performed on 7/10/13. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees recurrent symptomatic atrial fibrillation. The physician reviewer found the surgical services performed on 7/10/13 were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the documentation submitted for review, the patient presented with symptomatic paroxysmal atrial fibrillation in spite of a prior remote ablation in 2011 and suppressive antiarrhythmic medication trials. Since the patient continued to have significant symptoms in spite of attempts at rate control and rhythm control a second atrial fibrillation ablation procedure in this clinical setting was reasonable and medically appropriate and considered the standard of care in the medical community. The highest success in preventing atrial fibrillation with ablation is in those patients with paroxysmal (as opposed to persistent) atrial fibrillation (January, et al). Also, cryoablation has favorable results compared to radiofrequency ablation (Packer, et al). Given that the repeat ablation procedure performed on 7/10/13 was clinically indicated to relieve symptoms and is the standard of care in the medical community, the surgical services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer:
A 51-year-old female enrollee has requested authorization and coverage for Botox. The Health
Insurer has denied this request and reported that the requested service is investigational for the
treatment of the enrollee.

Context:
Summary Reviewer 1

A 51-year-old female enrollee has requested authorization and coverage for Botox. The Health
Insurer has denied this request and reported that the requested service is investigational for the
treatment of the enrollee. The physician reviewer found that Temporomandibular joint disorders
usually present with symptoms and signs such as pain, mandibular movement, dysfunction, or
joint sounds. Bruxism is characterized by teeth grinding. Botulinum toxin A (Botox) is a biologic
toxin which inhibits skeletal muscle through hindering the production of acetylcholine in the
nerve endings. The use of Botox for treatment of temporomandibular joint disorders and bruxism
is not consistent with U.S. Food and Drug Administration (FDA) indications. While there are
reports of the clinical use of Botox for the treatment of temporomandibular joint disorders and
bruxism, the clinical evidence in current medical literature is insufficient to demonstrate the
clinical efficacy of Botox in the treatment of temporomandibular joint disorders and bruxism or
that it is more beneficial than standard therapies including the use of occlusal devices, NSAIDs,
and physical therapy. Therefore, Botox is not likely to be more beneficial for treatment of the
patients condition than any available standard therapy.

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


Answer: A 64-year-old male enrollee has requested reimbursement for inpatient stay at telemetry level of care provided from 5/23/18 through 5/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition.

Answer: at the time of admission, the patient had a low potassium and an elevated troponin level. He had multiple cardiac risk factors, including hypertension, diabetes mellitus, congestive heart failure and advanced renal disease.

Answer: the potassium level was improved by 5/24/18. He did not have any chest pain or acute ischemia on admission

Context:
Summary Reviewer

A 64-year-old male enrollee has requested reimbursement for inpatient stay at telemetry level of care provided from 5/23/18 through 5/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that at the time of admission, the patient had a low potassium and an elevated troponin level. He had multiple cardiac risk factors, including hypertension, diabetes mellitus, congestive heart failure and advanced renal disease. Given these risk factors and the severity of his infection and wounds, it was reasonable to admit him to a telemetry level of care for 24 hours. The initial 24 hours is sufficient time to check serial echocardiogram and cardiac enzymes and have a cardiology consultation. Furthermore, the potassium level was improved by 5/24/18. He did not have any chest pain or acute ischemia on admission, and after monitoring and serial enzymes/echocardiograms, he could have been treated at a lower level of care from 5/25/18 through 5/30/18. Therefore, inpatient stay at telemetry level of care provided from 5/23/18 through 5/24/18 was medically necessary for the treatment of this patient. The records fail to demonstrate the medical necessity of inpatient stay at telemetry level of care provided from 5/25/18 through 5/30/18.

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


Answer: The patient is a 56-year-old male who sustained a ventricular fibrillation related cardiac arrest in the setting of an acute anterior ST-elevation myocardial infarction. The patient was hospitalized from 7/31/16 through 8/05/16.  He was successfully resuscitated and treated with drug eluting stent to the left anterior descending artery. Following the procedure, additional episodes of ventricular fibrillation were documented, and he was treated with cardioversion and amiodarone. Thrombus was noted at the site of the recent left anterior descending artery stent placement which was treated with angioplasty, and critical right coronary artery lesion was subjected to percutaneous coronary intervention/stenting. The ejection fraction following the procedure was 47%. The patient has requested reimbursement for wearable cardioverter defibrillator. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of this patient.

Context:
Summary Reviewer 3

The patient is a 56-year-old male who sustained a ventricular fibrillation related cardiac arrest in the setting of an acute anterior ST-elevation myocardial infarction. The patient was hospitalized from 7/31/16 through 8/05/16.  He was successfully resuscitated and treated with drug eluting stent to the left anterior descending artery. Following the procedure, additional episodes of ventricular fibrillation were documented, and he was treated with cardioversion and amiodarone. Thrombus was noted at the site of the recent left anterior descending artery stent placement which was treated with angioplasty, and critical right coronary artery lesion was subjected to percutaneous coronary intervention/stenting. The ejection fraction following the procedure was 47%. The patient has requested reimbursement for wearable cardioverter defibrillator. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of this patient.  The medical evidence has not demonstrated the superior efficacy of the device at issue in this patients case. There is a lack of support for an improvement of health outcomes when a wearable cardioverter defibrillator is deployed in this clinical setting. Implantable cardioverter defibrillator placement can be undertaken 90 days after a percutaneous coronary intervention/stenting procedure if the ejection fraction remains below 35 percent or 40 days after a myocardial infarction if there is no intervention and the ejection fraction remains below 35 percent.  There is lack of support for the device at issue in this case. Thus, the wearable cardioverter defibrillator was not likely to have been more effective than other treatment modalities. Based upon the information set forth above, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation.

Context:
Summary Reviewer 2

A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. The physician reviewer found that in this circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting an increased bleeding risk or percutaneous left atrial appendage exclusion using a Watchman device. The U.S. Food and Drug Administration (FDA) has approved the Watchman device. The Watchman device is an appropriate alternative in patients who are deemed to be at prohibitively high bleeding risk while on long-term anticoagulation, such as is documented with this patient. The requested services are likely to be more beneficial than the alternative of long-term anticoagulation in this patient with a documented high risk of recurrent bleeding. In sum, the requested percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device) is likely to be more efficacious than other available treatment options. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation.

Context:
Summary Reviewer 3

A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. The physician reviewer found that the Watchman device is an effective and relatively safe option for patients with atrial fibrillation who require but cannot take long-term anticoagulation. However, this patient underwent successful atrial fibrillation ablation with no documented recurrence of atrial fibrillation when the device had been regularly interrogated. Therefore, long-term anticoagulation would not be indicated to justify the need for a Watchman device. Thus, the superior efficacy of the requested percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device) has not been demonstrated. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: The patient is a 16-year-old female who has a history of a left knee anterior cruciate ligament reconstruction with a quadriceps tendon autograft in September 2018. The patientas parent has requested authorization and coverage for physical therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.

Answer: In the current case, the patient underwent a right knee ACL reconstruction with quadriceps autograft, as well as medial and lateral meniscus repairs in early March 2020. Postoperatively, she had a slow recovery of her range of motion but ultimately gained full extension and functional flexion. She had complaints with various activities such as walking on uneven surfaces

Answer: the patient has not fully recovered from her right knee surgery

Context:
Summary Reviewer

The patient is a 16-year-old female who has a history of a left knee anterior cruciate ligament reconstruction with a quadriceps tendon autograft in September 2018. The patientas parent has requested authorization and coverage for physical therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the literature related to rehabilitation after anterior cruciate ligament (ACL) reconstruction supports early weight bearing, early range of motion exercise, and closed kinetic chain activities. The early rehabilitation process should be monitored closely to protect against graft failure and other complications. As strength improves, open kinetic chain activities and more functionally advanced work can be introduced, although demanding physical activity is generally avoided during the first three postoperative months. Rehabilitation following ACL reconstruction, overall, can require a prolonged period of time. The entire rehabilitation process following ACL reconstruction, however, does not requires a formal therapy setting. Home-based programs have been shown to result in similar long-term outcomes to more clinically supervised programs, particularly for the recreational sports participant. The rehabilitation process can be more complicated, however, particularly for return to activities placing significant stress on the knee. Regaining higher level neuromuscular control of core muscles and optimizing other biomechanics factors are important to improve functional outcomes and mitigate risk of re-injury of the repaired ACL, as well as contralateral knee injury. Assessment and treatment of the injured knee, as well as the addressing of potentially disadvantageous compensatory biomechanics is appropriate for a comprehensive rehabilitation program following ACL repair. Ultimately, each rehabilitation program needs to be reviewed on an individual basis, depending on the specific functional needs in each case. Therapy protocols after meniscal repair typically call for avoiding weight bearing and excessive range of motion in the early postoperative period. There is, however, no clear evidence-based consensus on optimal protocols, as accelerated and more aggressive programs have also been shown to have benefit, particularly when meniscal repairs are performed in association with an ACL reconstruction. In any case, a period of supervised formal therapy following meniscal repair is warranted to initiate the program, followed by a transition to self-directed exercises when possible and appropriate. In the current case, the patient underwent a right knee ACL reconstruction with quadriceps autograft, as well as medial and lateral meniscus repairs in early March 2020. Postoperatively, she had a slow recovery of her range of motion but ultimately gained full extension and functional flexion. She had complaints with various activities such as walking on uneven surfaces, but there are no indications that she has any limitations with her mobility-related activities of daily living at that time. Although the patient has not fully recovered from her right knee surgery, the medical necessity of the requested additional 24 therapy visits is not established. There are no exercises that she is performing in the formal therapy setting that could not be performed independently or substituted with independent exercise. There are no indications that she is unable to do an appropriate home exercise program. At this stage many months postoperatively, and with full knee extension already established long ago, there is no benefit of ongoing formal manual therapy over stretching and use of self-applied modalities (e.g., foam rollers) that can be performed independently. She will have a guarded prognosis with respect to future injuries if she continues to participate in activities and sports such as soccer, but the additionally proposed therapy in question is not expected to marginally improve her risk profile. Therefore, the requested physical therapy is not medically necessary for the treatment of this patient.

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


Answer: A 26-year-old female enrollee has requested reimbursement for DecisionDx testing performed on 4/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma.

Context:
Summary Reviewer 3

A 26-year-old female enrollee has requested reimbursement for DecisionDx testing performed on 4/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx-Melanoma test is an attempt to determine risk of recurrence for early stage melanoma. However, the treatment protocol for follow up of melanoma patients is summarized in the National Comprehensive Cancer Network (NCCN) guidelines. These guidelines note there is a lack of data to support using adjuvant therapy based on DecisionDx testing results. The follow up of melanoma patients is not tailored to each patient risk of recurrence, but rather is global to all patients with melanoma. Given these findings, the DecisionDx testing performed on 4/28/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 44-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan of parathyroid gland provided on 7/19/16. The Health Plan has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees hyperparathyroidism.

Answer: In this case, the patient presented with a diagnosis of primary hyperparathyroidism complicated by the presence of thyroid nodules.

Context:
Summary Reviewer 2

A 44-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan of parathyroid gland provided on 7/19/16. The Health Plan has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees hyperparathyroidism. The physician reviewer found that in the medical literature, Eslamy and Ziessman noted that the clinical diagnosis of primary hyperparathyroidism is based largely on serum laboratory test results, as patients often are asymptomatic. Given that approximately 90% of cases are due to a single parathyroid adenoma, the procedure of choice is the selective surgical excision of the hyperfunctioning parathyroid gland after its preoperative identification and localization at radiologic imaging. The authors noted that SPECT, when combined with CT, is particularly helpful for preoperative localization: The three-dimensional functional information from SPECT is fused with the anatomic information obtained from CT. In addition, knowledge of the anatomy and embryologic development of the parathyroid glands and the pathophysiology of primary hyperparathyroidism aid in the identification and localization of hyperfunctioning glands. In this case, the patient presented with a diagnosis of primary hyperparathyroidism complicated by the presence of thyroid nodules. In this clinical setting, the minimally invasive parathyroidectomy procedure is the standard of care. Medical literature supports the use of SPECT/CT scan for the preoperative localization of the tumor. As such, the SPECT scan of parathyroid gland provided on 7/19/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: The patient is a 38-year-old female with a history of chronic left hip pain in the groin related to CAM type femoroacetabular impingement, with a small pincer and associated tear of the anterior-superior labrum. The patient has requested reimbursement for hip arthroscopy performed on 12/03/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient.

Answer: In this patientas case, the procedures performed at the time of hip arthroscopy

Answer: included arthroscopic surgery on her left hip consisting of acetabular rim trimming, repair of the labral tear, femoral osteochondroplasty, and capsular plication. The operative report describes the deformity that was corrected. Physical therapy was not helping at three months

Context:
Summary Reviewer

The patient is a 38-year-old female with a history of chronic left hip pain in the groin related to CAM type femoroacetabular impingement, with a small pincer and associated tear of the anterior-superior labrum. The patient has requested reimbursement for hip arthroscopy performed on 12/03/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Femoroacetabular impingement is a common condition among young adults. Griffin and colleagues compared physical therapy and surgery for management of this condition. Among 348 participants, 171 participants were treated with hip arthroscopy and 177 were treated with hip physical therapy. Both treatments improved the quality of life. However, hip arthroscopy resulted in greater improvement than physical therapy. In this patientas case, the procedures performed at the time of hip arthroscopy were appropriate and are known to be beneficial. These included arthroscopic surgery on her left hip consisting of acetabular rim trimming, repair of the labral tear, femoral osteochondroplasty, and capsular plication. The operative report describes the deformity that was corrected. Physical therapy was not helping at three months, and surgery was medically indicated. Therefore, hip arthroscopy performed on 12/03/19 was medically necessary for the treatment of this patient.

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


Answer: A 26-year-old female enrollee has requested reimbursement for CPT code 81291 performed on 10/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a family history of a clotting disorder.

Context:
Summary Reviewer 3

A 26-year-old female enrollee has requested reimbursement for CPT code 81291 performed on 10/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a family history of a clotting disorder. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Knowledge of the patients MTHFR status does not impact her care during pregnancy. All pregnant patients are advised to have adequate folic acid intake to prevent neural tube defects.  There is no recommended treatment during pregnancy for a known mutation in the MTHFR gene. Thus, the superior efficacy of CPT code 81291 performed on 10/11/17 has not been established. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 58-year-old female enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) provided from 1/22/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees overactive bladder.

Answer: the records document that this patient has a diagnosis of refractory overactive bladder. She has failed multiple second- and third-line therapies and is not a candidate for certain therapies including sacral neuromodulation as noted by the provider. She has responded to PTNS.

Answer: this patient has been treated with multiple second- and third-line therapies and is not a candidate for sacral neuromodulation

Context:
Summary Reviewer

A 58-year-old female enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) provided from 1/22/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees overactive bladder.   The physician reviewer found the records document that this patient has a diagnosis of refractory overactive bladder. She has failed multiple second- and third-line therapies and is not a candidate for certain therapies including sacral neuromodulation as noted by the provider. She has responded to PTNS. Continued treatment with PTNS is medically necessary, and a nationally accepted standard of care for this patient. The procedure for PTNS consists of the insertion of a needle above the medial malleolus into the posterior tibial nerve followed by the application of low-voltage electrical stimulation that produces sensory and motor responses. The recommended course of treatment is an initial series of 12 weekly office-based treatments followed by an individualized maintenance treatment schedule. Evidence from multiple randomized placebo-controlled trials supports the safety and clinical efficacy of PTNS. The available 12- to 36-month evidence appears consistent with maintained efficacy in relieving symptoms of overactive bladder (OAB) and urinary voiding dysfunction. The American Urological Association (AUA) and Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) guidelines support use of PTNS as third-line treatment in a carefully selected patient population with overactive bladder. Given that this patient has been treated with multiple second- and third-line therapies and is not a candidate for sacral neuromodulation, the PTNS provided from 1/22/16 forward was and is medically necessary for treatment of this patients refractory overactive bladder. Based on the foregoing discussion, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

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


Answer: A 43-year-old female enrollee has requested authorization and coverage for breast reduction mammoplasty. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees symptomatic macromastia.

Answer: The patient has well documented symptoms for macromastia and medical treatments have not improved her symptoms.

Answer: In this patients case, the records document that she has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia.

Context:
Summary Reviewer

A 43-year-old female enrollee has requested authorization and coverage for breast reduction mammoplasty. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees symptomatic macromastia. The physician reviewer found that Breast reduction surgery is medically necessary in this patients case. The patient has well documented symptoms for macromastia and medical treatments have not improved her symptoms. The medical literature indicates that symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for treatment of this condition. Additionally, nonoperative treatments are not likely to improve pain. Instead, the evidence appears to support that surgery may be the most effective treatment for symptomatic relief.  Collins and Kerrigan report that data from the BRAVO (Breast Reduction Assessment Value and Outcomes) study, which prospectively followed 243 patients with symptomatic macromastia, found that nonoperative treatment options did not provide lasting relief from pain. The authors noted  Breast hypertrophy has a significant impact on womens health status and quality of life as measured by validated and widely used self-report instruments including the SF-36, MPQ, MBSRQ, and EuroQol. In women presenting for surgery, nonsurgical measures including weight loss, physical therapy, special brassieres, and medications were not effective in providing permanent relief of breast-related symptoms. In contrast, both pain and overall health status were markedly improved by breast reduction, essentially restoring functional status to that of age-matched norms. A 2014 study by Strong and Hall-Findlay concluded, We found that reduction mammaplasty has a positive impact on a range of symptoms, even with lower volume resections and regardless of body surface area-calculated adjustments. This adds further weight to the argument that patients should not be denied access to the surgery based on arbitrary volume restrictions. We advocate freedom for the surgeon to make a decision on potential benefits of surgery based around the needs of each individual patient. In this patients case, the records document that she has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. Breast reduction is a treatment that has been proven effective and curative for symptomatic macromastia. Evidence based peer reviewed studies confirm the benefits of breast reduction surgery for individuals with upper torso pain due to breast hypertrophy. As such, nonoperative treatments are unlikely to improve this patients pain. Therefore, the breast reduction mammoplasty is medically necessary for the treatment of this patients medical condition.
Therefore, for the reasons stated above, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

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


Answer: A 68-year-old female enrollee has requested reimbursement for human epididymis protein 4 (HE4) testing performed on 9/20/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.

Context:
Summary Reviewer 3

A 68-year-old female enrollee has requested reimbursement for human epididymis protein 4 (HE4) testing performed on 9/20/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that for patients with localized endometrial cancer, if the patient has elevated CA-125 at the time of initial diagnosis, then current National Comprehensive Cancer Network guidelines recommend serial testing of serum CA-125 for recurrence monitoring.  Multiple other serum proteins expressed by endometrial cancer are currently being investigated as possible markers for recurrent disease, including human epididymis protein 4 (HE4). Secreted HE4 has been extensively studied as a serum biomarker for proposed uses for either screening, detection of recurrence or monitoring of therapeutic response for ovarian cancer. Secreted HE4 is also associated with endometrial cancer, and continues to be studied as a potential biomarker for differentiating between malignant and benign pelvic masses, screening for malignancy, prognosis, recurrence detection, and therapeutic response. However, it is not currently accepted as a standard of care for patients with endometrial cancer. The study by Abbink and colleagues compared HE4 to the standard of care marker CA-125. Although the authors indicated the possibility of superior performance of HE4 compared to CA-125 for detection of recurrence in patients with endometrial cancer, they also noted that a future prospective study on a larger cohort of patients with endometrial cancer is needed to affirm the preoperative value of serum HE4 and the use of HE4 in routine follow-up. At this time, the superior efficacy of the services at issue has not been established. Thus, HE4 testing performed on 9/20/18 was not likely to have been more effective than other methods of evaluating this patient.

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


Answer: A 29-year-old female enrollee has requested reimbursement for human papilloma virus (HPV) testing performed on 9/29/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue.

Answer: The patient has a history of high-risk HPV genotype 16.

Context:
Summary Reviewer 1

A 29-year-old female enrollee has requested reimbursement for human papilloma virus (HPV) testing performed on 9/29/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue.  The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting. The patient has a history of high-risk HPV genotype 16. She has not been consistent with her follow-up. Recent changes in the American Society of Colposcopy and Cervical Pathology (ASCCP) guidelines have moved to a risk-based assessment for the management of cervical cancer screening. HPV testing is the preferred manner of assessing risk. In this case, because data is missing, the guideline algorithm recommends clinical judgment. Therefore, HPV testing performed on 9/29/20 was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.

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


Answer: A 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic.

Answer: In this patients case, her breasts were not described as particularly dense.

Answer: she had a questionable area of developing new architectural distortion in one breast.

Context:
Summary Reviewer 1

A 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic.  The physician reviewer found that the Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were not described as particularly dense.  However, she had a questionable area of developing new architectural distortion in one breast.  In this setting, breast tomosynthesis is valuable in separating out overlapping structures and possibly demonstrating an otherwise occult mass.  Thus, breast tomosynthesis performed on 8/04/16 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: A 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic.

Context:
Summary Reviewer 2

A 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic.  The physician reviewer found that the current medical literature supports the service at issue in this patients case.  Per Skaane and colleague, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Therefore, breast tomosynthesis performed on 8/04/16 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: A 24-year-old male enrollee has requested authorization and coverage for cervical spine surgery at the C4-5 level using the Depuy VG2 allograft cervical space and Depuy Synthes Stim-line instrumentation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition.

Answer: this patient presents with progressively worsening and severe neck, right shoulder/arm, and mid-back pain with associated headaches. Signs and symptoms have been reportedly consistent with possible cervical myelopathy, including hand clumsiness and hyperreflexia. His pain is interfering with sleep and activities of daily living. There is imaging evidence of a significant anterior osteophyte at the C5 level with history of superior endplate fracture, and degenerative changes at C4/5 without focal neural compression. There is discogram evidence of severe concordant pain at C4/5. Detailed evidence of a recent comprehensive nonoperative treatment protocol trial and failure has been submitted. The records suggest a history of dysphagia with recent improvement following discogram.

Context:
Summary Reviewer

A 24-year-old male enrollee has requested authorization and coverage for cervical spine surgery at the C4-5 level using the Depuy VG2 allograft cervical space and Depuy Synthes Stim-line instrumentation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient presents with progressively worsening and severe neck, right shoulder/arm, and mid-back pain with associated headaches. Signs and symptoms have been reportedly consistent with possible cervical myelopathy, including hand clumsiness and hyperreflexia. His pain is interfering with sleep and activities of daily living. There is imaging evidence of a significant anterior osteophyte at the C5 level with history of superior endplate fracture, and degenerative changes at C4/5 without focal neural compression. There is discogram evidence of severe concordant pain at C4/5. Detailed evidence of a recent comprehensive nonoperative treatment protocol trial and failure has been submitted. The records suggest a history of dysphagia with recent improvement following discogram. Given the persistence of significantly abnormal findings, severe pain and functional limitations, imaging findings of cervical spondylosis with concordant findings at C4/5, and exhaustion of conservative treatment, surgical intervention is medically indicated and supported by evidence-based medical criteria. Therefore, the requested cervical spine surgery at the C4-5 level using the Depuy VG2 allograft cervical spacer and Depuy Synthes Slim-line instrumentation is medically necessary for the treatment of this patient.

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


Answer: A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 9/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition.

Context:
Summary Reviewer 2

A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 9/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that based on the patients vision loss and progression, corneal collagen crosslinking was the most appropriate and effective treatment available. The medical evidence has demonstrated that corneal collagen crosslinking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. Furthermore, there was a lack of treatment options available to slow or halt disease progression. In sum, corneal collagen crosslinking performed on 9/04/18 was likely to have been of greater benefit than other treatment options.

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


Answer: The patient is a 40-year-old female with a history of breast cancer. On 7/01/19, she underwent a bilateral mastectomy with bilateral deep inferior epigastric perforator (DIEP) flap reconstruction.

Answer: the service in dispute in this case is code 15734. Code 15734 describes muscle, myocutaneous, or fasciocutaneous flap, trunk.

Context:
Summary Reviewer

The patient is a 40-year-old female with a history of breast cancer. On 7/01/19, she underwent a bilateral mastectomy with bilateral deep inferior epigastric perforator (DIEP) flap reconstruction. The physician reviewer found that the DIEP flap was for breast reconstruction and was medically necessary. However, the service in dispute in this case is code 15734. Code 15734 describes muscle, myocutaneous, or fasciocutaneous flap, trunk. This code is used in the setting of ventral hernia repair or for repair of wide diastasis recti. The medical records do not support this code in this patientas case. Based on the submitted medical records, there was no ventral hernia repair or repair of wide diastasis recti reported. Per the submitted records, no abdominal weakness or hernia was reported as being present to require a separation of parts repair. Therefore, 15734-59-62 and 15734-62 performed on 7/01/19 were not medically necessary for the treatment of this patient.

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


Answer: A 53-year-old female enrollee has requested reimbursement for gene testing performed on 7/5/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees bilateral thyroid nodules.

Answer: This patients biopsy was suspicious for follicular lesion of undetermined significance.

Context:
Summary Reviewer 2

A 53-year-old female enrollee has requested reimbursement for gene testing performed on 7/5/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees bilateral thyroid nodules. The physician reviewer found that there is sufficient support for the Afirma gene test performed on 7/5/16 in this clinical setting. This patients biopsy was suspicious for follicular lesion of undetermined significance. The Afirma testing was suspicious, and a determining factor in delineating the further course of action to assess whether a surgical procedure was warranted. Afirma testing is considered standard protocol on fine needle aspirations performed on thyroid nodules. In sum, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: The parent of a four-year-old male enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder.

Answer: he Health Insurer has authorized 25 hours per week of ABA services.

Answer: n this case, the patient demonstrates delays in social, cognitive, adaptive and executive functioning deficits and continues to demonstrate maladaptive behaviors of aggression, physical stereotypy and perseveration.

Context:
Summary Reviewer

The parent of a four-year-old male enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder. The physician reviewer found the Health Insurer has authorized 25 hours per week of ABA services. Several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes (Roane et al; Myers et al). The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the patient demonstrates delays in social, cognitive, adaptive and executive functioning deficits and continues to demonstrate maladaptive behaviors of aggression, physical stereotypy and perseveration. In this clinical setting, 40 hours per week of ABA therapy is medically necessary for treatment of the patients medical condition. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

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


Answer: The patient is a 54-year-old female with a family history of a sister who died from ovarian cancer, father with colon cancer, and grandmother with possible primary peritoneal cancer. The patient was noted to have a 1 cm ovarian cyst with no concerning features. Her uterus was noted to be normal. The patients evaluation included detailed genetic consultation and testing. The testing did not show any high risk mutations. As a result, the genetic counselor did not place the patient in a high risk category for gynecologic malignancies. The patient has requested authorization and coverage for hysterectomy. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary. The patient has elected to undergo a prophylactic hysterectomy and bilateral salpingo-oophorectomy due to her family history.

Context:
Summary Reviewer

The patient is a 54-year-old female with a family history of a sister who died from ovarian cancer, father with colon cancer, and grandmother with possible primary peritoneal cancer. The patient was noted to have a 1 cm ovarian cyst with no concerning features. Her uterus was noted to be normal. The patients evaluation included detailed genetic consultation and testing. The testing did not show any high risk mutations. As a result, the genetic counselor did not place the patient in a high risk category for gynecologic malignancies. The patient has requested authorization and coverage for hysterectomy. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary. The patient has elected to undergo a prophylactic hysterectomy and bilateral salpingo-oophorectomy due to her family history. However, genetic counseling and testing do not place her in a high risk category for epithelial ovarian cancer, fallopian tube cancer or uterine cancer. Current recommendations reserve risk reducing surgery for patients in the highest risk categories with genetic mutations such as BRCA1, BRCA 2 and Lynch syndrome. Based on the patients family history and genetic testing results, she does not have a strong clinical indication for surgical cancer prophylaxis. Accordingly, the requested hysterectomy is not medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

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


Answer: The parent of a 16-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 12/13/13. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees ulcerative colitis.

Context:
Summary Reviewer 2

The parent of a 16-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 12/13/13. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found in general, diminished or suboptimal response to infliximab or adalimumab can be managed in several ways such as shortening the interval between doses, increasing the dose, switching to a different anti-TNF agent or switching to a non-anti-TNF agent based on clinical observation in lieu of Anser IFX testing. In this patients case, the medical records submitted for review do not support acute loss of therapeutic response nor acute disease flare. There are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. In addition, the clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. In sum, the testing at issue was not clinically indicated and not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 43-year-old female enrollee has requested reimbursement for molecular pathology testing provided on 4/14/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer.

Context:
Summary Reviewer 3

A 43-year-old female enrollee has requested reimbursement for molecular pathology testing provided on 4/14/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer. The physician reviewer found the molecular pathology testing provided on 4/14/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers (Brose, et al; Thompson and Easton). BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers (Liede, et al; Tai, et al; Ferrone, et al). In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. The Amsterdam criteria and the Bethesda consensus guidelines evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. Notably, the Amsterdam criteria have low sensitivity in HNPCC detection so the Bethesda guidelines were developed (Umar, et al). However, these guidelines are highly focused on patients with colorectal cancer who have microsatellite instability although the occurrence of microsatellite instability in other Lynch syndrome associated tumors was discussed. The most common extracolonic tumors in Lynch syndrome are endometrial, ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral cancers. This patients family history is suggestive of a breast/ovarian cancer syndrome. The MyRisk panel is appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Therefore, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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