Answer: The parent of a child enrollee has requested 51.6 hours per month of one-on-one applied behavioral analysis (ABA) therapy for treatment of the autism spectrum disorder.

Answer: the patient demonstrates multiple problematic behaviors which include aggression, inflexibility/non-compliance and eloping. These behaviors place the patient at significant risk given her lack of awareness.

Answer: the patients unwillingness to participate in low preference transitions within the community has made it increasingly difficult for her to demonstrate mastery of her adaptive skillsets and behavioral goals.

Context: Nature of Statutory Criteria/Case Summary: The parent of a child enrollee has requested 51.6 hours per month of one-on-one applied behavioral analysis (ABA) therapy for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that there is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. In this case, the patient demonstrates multiple problematic behaviors which include aggression, inflexibility/non-compliance and eloping. These behaviors place the patient at significant risk given her lack of awareness. In addition, the patients unwillingness to participate in low preference transitions within the community has made it increasingly difficult for her to demonstrate mastery of her adaptive skillsets and behavioral goals. Final Result: The reviewers determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: Anenrollee has requested authorization and coverage for lumbar/sacral transforaminal epidural injection.

Answer: This patient has lumbar radiculopathy, and the probable etiology is either scaring or recurrent disc protrusion at the site of the prior laminectomy.

Context: Nature of Statutory Criteria/Case Summary: Anenrollee has requested authorization and coverage for lumbar/sacral transforaminal epidural injection.  Findings:  The physician reviewer found that  the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has lumbar radiculopathy, and the probable etiology is either scaring or recurrent disc protrusion at the site of the prior laminectomy.  However, the records do not document that he has had a recent trial of conservative therapy.  The American Pain Society recommends a trial of conservative therapy before starting interventional therapy.  Conservative therapy includes physical therapy, chiropractic therapy or a home exercise program.  All told, the requested lumbar/sacral transforaminal epidural injection is not medically indicated for the treatment of this patient. Final Result: The reviewers determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested authorization and coverage for Zepatier 50-100 mg, one per day for 12 weeks for treatment of the enrollees hepatitis C.

Answer: In this patients case, NS5A resistance testing results were not provided.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg, one per day for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated (except those with limited life expectancy due to non-liver-related conditions), regardless of fibrosis stage.  The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. However, Zepatier is significantly less effective when NS5A resistance is present, and a different regimen is needed (Zepatier and ribavirin for 16 weeks).  In this patients case, NS5A resistance testing results were not provided.  For these reasons, although hepatitis C treatment is needed, Zepatier 50-100 mg, one per day for 12 weeks is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.

Answer: In this patients case, the records document dense breast tissue.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records document dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast tomosynthesis was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested reimbursement for a joint jaw oral device (occlusal orthotic device)

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a joint jaw oral device (occlusal orthotic device).Findings:  The physician reviewer found that there is sufficient support for the device at issue in this clinical setting.  Splint therapy has been shown to be beneficial in patients with temporomandibular joint disorder and myofascial pain.  Oral devices have been shown to decrease symptoms in 70 to 90% of cases.  The majority of patients with temporomandibular joint disorder can be treated with a single stabilization splint. Final Result: The reviewer determined that the device at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested reimbursement for digital breast tomosynthesis.

Answer: the patient underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination.  In addition, the patient had an automated whole breast sonogram examination as well as a focused hand-held bilateral breast sonogram.  The current images were compared to a prior mammogram dated 4/12/11, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as being extremely dense.  Considering the palpable abnormalities and the negative results on her imaging studies, it was recommended that the lumps be managed on clinical grounds. The Health Plan denied coverage for the bilateral breast tomosynthesis portion of the examination as investigational for the evaluation of this patient.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis.  Findings:  Three physician reviewers found that the patient underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination.  In addition, the patient had an automated whole breast sonogram examination as well as a focused hand-held bilateral breast sonogram.  The current images were compared to a prior mammogram dated 4/12/11, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as being extremely dense.  Considering the palpable abnormalities and the negative results on her imaging studies, it was recommended that the lumps be managed on clinical grounds. The Health Plan denied coverage for the bilateral breast tomosynthesis portion of the examination as investigational for the evaluation of this patient.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 scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, there are multiple reasonable indications for tomosynthesis. She has breasts that have been described as being extremely dense. It is specifically those patients who have very dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Secondly, in the clinical setting of palpable masses, it is imperative for the radiologist to be as sure as possible that there is not a radiographic correlate.Final Result: All three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturnedCredentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested orchiectomy and vaginoplasty/labiaplasty for treatment of the enrollees gender dysphoria.

Answer: Based on the medical records provided, this patient has well-documented gender dysphoria. She has previously undergone parts of gender transition with apparent success. She has been undergoing hormonal therapy and has been living as a female.

Answer: The Health Plan had indicated that this patient was not compliant with treatment regimens, office visits and necessary laboratory tests.

Answer: the submitted documentation supports that this patient has addressed these issues

Context: Nature of Statutory Criteria/Case Summary:An enrollee has requested orchiectomy and vaginoplasty/labiaplasty for treatment of the enrollees gender dysphoria. Bilateral orchiectomies and vaginoplasty/labiaplasty are part of the surgical transition process for male to female transition. Based on the medical records provided, this patient has well-documented gender dysphoria. She has previously undergone parts of gender transition with apparent success. She has been undergoing hormonal therapy and has been living as a female. Furthermore, the medical literature recommends that after a diagnosis of gender identity disorder, the therapeutic approach commonly includes three phases (triadic therapy): a real-life experience in the desired role, hormones of the desired gender, and surgery to change the genitalia and other sex characteristics. In this patients case, the recommended criteria have been established. For treatment of her gender dysphoria, her external anatomy should be more consistent with a female anatomy than of a male. Bilateral orchiectomy and vaginoplasty/labiaplasty are consistent with the appropriate female anatomy. The Health Plan had indicated that this patient was not compliant with treatment regimens, office visits and necessary laboratory tests. However, the submitted documentation supports that this patient has addressed these issues and her most recent office visits and therapy sessions appear consistent with the Health Plans clinical criteria. As such, the medical documentation supports the requested services in this patients case.Findings:The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested reimbursement for the removal of tissue from the breasts performed for treatment of the enrollees gynecomastia.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the removal of tissue from the breasts performed for treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the procedure at issue. The patients pain and discomfort is not adequately supported in the medical documentation as likely due to distention and tightness from hypertrophied breast. In addition, the patients grade of gynecomastia is not adequately defined and photographs were not provided for review. The records do not demonstrate a concern for possible malignancy based on examination detail and other results. Other possible causes had not been sufficiently evaluated, including relevant laboratory studies and endocrine work-up. Therefore, the removal of tissue from the breasts performed has not been established as medically necessary for treatment of the patients. Final Result: The reviewers determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested authorization and coverage for wireless capsule endoscopy for evaluation of the enrollees Crohns disease, ulcer and diarrhea.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy for evaluation of the enrollees Crohns disease, ulcer and diarrhea. Findings:  The physician reviewers found that current American Society for Gastrointestinal Endoscopy (ASGE) guidelines for endoscopy in inflammatory bowel disease recommend the use of capsule endoscopy in the diagnosis of Crohns disease. Data from retrospective and prospective studies have shown that capsule endoscopy is useful for the diagnosis of Crohns disease even if imaging tests such as small bowel follow through and ileoscopy are negative or unsuccessful. Capsule endoscopy has been proven to be more sensitive in the detection of small bowel Crohns disease than alternatives such as CT scan, small bowel follow-through, and enteroclysis, and capsule endoscopy resulted in a change in management in a significant number of patients based on findings missed by other tests. Capsule endoscopy is a valuable tool in evaluation of patients with Crohns disease and is more sensitive than conventional ileocolonoscopy for the diagnosis of small bowel Crohns disease activity. For these reasons, the requested wireless capsule endoscopy is likely to provide useful diagnostic information in this case, and is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in gastroenterology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested laser hair removal for their arms, axilla, chest, face, neck, low back. The patient was born with genetics to grow the terminal hair in her arms, axilla, chest, face, neck and low back.

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested laser hair removal for their arms, axilla, chest, face, neck, low back. The patient was born with genetics to grow the terminal hair in her arms, axilla, chest, face, neck and low back. It would be abnormal for a female to have terminal hair on the face, chest, neck and low back.  This hair growth in a woman is known as hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in female body parts that are normally found in males. As such, the removal of terminal hair to the face, chest, neck and low back is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. These treatments will create a more feminine appearance for this patient and provide more than a minimal improvement in appearance. Moreover, removal of terminal hair to the face, chest, neck and low back will also improve this patients emotional function. However, females would be expected to have terminal hair in the axilla and on their arms. Therefore, removal of terminal hair to the axilla or arms is not medically necessary for treatment of this patient. Nor would removal of hair on the axilla and arms be considered reconstructive surgery, as the presence of hair in these areas is not considered an abnormal structure.Final Result: The reviewer determined that a portion of the requested services is medically necessary, and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. In addition, the guidelines recommend that treatment-naive genotype 4 patients should be treated with Harvoni for 12 weeks. This is based on the SYNERGY trial for Harvoni, which showed a 100% cure rate despite including some patients who had failed prior therapy (Kohli, et al). The AASLD/IDSA guidelines cite data showing decreased survival with delay in therapy (Jezequel, et al). For these reasons, treatment with Harvoni for 12 weeks is medically necessary for the treatment of the patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested Rituxan for treatment of the enrollees antiphospholipid syndrome.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan for treatment of the enrollees antiphospholipid syndrome.  Findings: Two reviewers found that Antiphospholipid syndrome is a serious disorder of abnormal arterial and venous thromboses. Antiphospholipid syndrome is an autoimmune disorder where antibodies are generated against self-antigens that drive the clotting cascade. Some patients have antiphospholipid syndrome and systemic lupus erythematosus whereas others have antiphospholipid syndrome alone. Anticoagulation is the mainstay of therapy, which includes enoxaparin, warfarin, and aspirin. Some studies have suggested that the addition of Plaquenil may be effective in preventing thromboses. All these therapies were tried in this case but the patient still developed clots. Rituxan is a monoclonal antibody directed at CD20, an antigen expressed on B cells. Thus, Rituxan can induce B cell cytopenia and reduction in antibody producing B cells. Rituxan is commonly used in autoimmune disorders based on this mechanism (Gurcan, et al; Rastetter, et al; Zaja, et al). Therefore, Rituxan has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and hematology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested authorization and coverage for Harvoni 90-400 mg tablets for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 1a.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg tablets for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 1a. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 90-400 mg daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder.

Answer: In this case, the patient presents with maladaptive behaviors that include elopement, disrobement, anger outbursts and self-stimulatory behavior

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the request for 30 hours per week of ABA services have been established as medically necessary for treatment of the patients autism. In this case, the patient presents with maladaptive behaviors that include elopement, disrobement, anger outbursts and self-stimulatory behavior and ABA services can be utilized to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with autism. Therefore, ABA therapy at the frequency of the recommended 30 hours per week is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.

Answer: In this patients case, her breasts have been described as heterogeneously dense.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts have been described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor, especially considering the area of right-sided asymmetry.  Thus, digital breast tomosynthesis was likely to have been more efficacious than other treatment alternatives.Final Result: Three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested reimbursement for the digital breast tomosynthesis for the evaluation of the enrollees medical condition.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for the evaluation of the enrollees medical condition. Findings:  The physician reviewers found that tomosynthesis often allows radiologists to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. Final Result: Two of the three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested the ReWalk robotic exoskeleton system for treatment of her spinal cord injury (paraplegia).

Answer: the patient has a history of spinal cord injury with lower thoracic paraplegia.

Context: Nature of Statutory Criteria/Case Summary:   An enrollee has requested the ReWalk robotic exoskeleton system for treatment of her spinal cord injury (paraplegia). Findings:  Three physician reviewers found that per the submitted documentation, robotic exoskeleton systems are intended to enable individuals with spinal cord injury at levels T7 to L5 to perform ambulatory functions with supervision of a specially trained companion in accordance with the user assessment and training certification program. In this case, the patient has a history of spinal cord injury with lower thoracic paraplegia. At this level of injury, the patient should be able to perform all essential activities of daily living at a modified independent wheelchair level, consistent with her spinal cord injury. She would be able to use standard or adapted exercise equipment for upper body strengthening and cardiovascular conditioning. She could be expected to be able to stand and ambulate with the use of conventional lower extremity orthoses potentially at a community level which would be included as standard available therapy. Use of a standing frame and regular standing program could be included in an independent home exercise program. In terms of pressure ulcers, performing regular pressure relief while in her wheelchair is the standard of care and an integral part of spinal cord injury education and ongoing management. Lastly, there is a lack of quality studies comparing the requested device against conventional treatments. In sum, the requested ReWalk robotic exoskeleton system is not likely to be more beneficial over other treatment options. Final Result: Three reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in physical medicine and rehabilitation and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.

Context: Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that performance of three dimensional breast imaging in this patient was indicated since the medical literature has been demonstrated that the sensitivity and specificity of three dimensional breast imaging is superior to two dimensional imaging alone for the detection of occult, non-palpable breast cancer. Three dimensional tomosynthesis allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. All told, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested applied behavior analysis (ABA) services for treatment of his autism.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested applied behavior analysis (ABA) services for treatment of his autism.  Findings: Two physician reviewers found that there is sufficient support for the requested services in this patients case.  The requested ABA services are medically necessary for modification of this patients autism spectrum disorder.  The requested number of hours of ABA services are well within the guidelines of best medical practice.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, exists and can be utilized to improve overall neurologic health.  ABA therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with autism spectrum disorder.  In sum, the requested services ABA services are medically indicated for the treatment of this patient.  Final Result: Two reviewers determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  One reviewer is actively practicing and is board certified in neurology with special qualification in child neurology.  One reviewer is actively practicing and is board certified in neurology with special qualification in child neurology.  One reviewer is actively practicing and is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested 10 hours per week of applied behavioral analysis (ABA) therapy, 10 hours per month of supervision and 2 hours per month of parent training for treatment of his medical condition

Answer: In this case, the patient has been treated with ABA services with documented progress in social skills with peers and adults. However, he requires prompting to complete his tasks. The patient has deficits related to autism that require ABA services.

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested 10 hours per week of applied behavioral analysis (ABA) therapy, 10 hours per month of supervision and 2 hours per month of parent training for treatment of his medical condition. Findings:  Two physician reviewers found that there is sufficient support for the requested services in the peer reviewed literature in this clinical setting. According to Foxx, The only interventions that have been shown to produce comprehensive, lasting results in autism have been based on the principles of ABA. In this case, the patient has been treated with ABA services with documented progress in social skills with peers and adults. However, he requires prompting to complete his tasks. The patient has deficits related to autism that require ABA services. As recommended by the patients ABA provider, 10 hours per week of ABA therapy, 10 hours per month of supervision and 2 hours per month of parent training is medically necessary for this patients autism. Final Result: The reviewers determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in child neurology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested proton beam radiation therapy for treatment of her medical condition.

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested proton beam radiation therapy for treatment of her medical condition.   Findings:  Two physician reviewers found that the difference between proton and photon irradiation is that the protons stop abruptly in the tissue (Bragg Peak) so there is less exit dose through normal tissue. The use of proton therapy is an accepted radiation technology, that has proven efficacy and tolerability as it is simply another means to deliver radiation. Certain conditions such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system (CNS) malignancies are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. There is abundant data on proton therapy for sinonasal cancers as well, and proton therapy is an accepted treatment modality. While proton therapy is not an accepted standard outside of sinonasal cancers abutting critical structures or in the setting of re-irradiation of targets abutting critical CNS structures, both of these situations apply in this patients case. In general, proton therapy is more effective in sparing the normal tissues in and around the base of skull. Thus, the requested proton beam radiation therapy is likely to be more beneficial in treating this patients squamous cell carcinoma than any other available standard therapy.  Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in radiation oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested Synvisc One injections in both knees for treatment of her bilateral knee pain.

Answer: In this case, the patient has been diagnosed with bilateral knee osteoarthritis, worse on the right. She has undergone two prior viscosupplementation injections with long-term pain reduction documented and ability to avoid surgery. She has failed to respond to other conservative treatment.

Context: Nature of Statutory Criteria/Case Summary:    An enrollee has requested Synvisc One injections in both knees for treatment of her bilateral knee pain.  Findings:  The physician reviewer found that evidence-based medical peer-reviewed literature supports the use of repeat series of viscosupplementation (hyaluronan) injections for the treatment of pain in patients with osteoarthritis of the knee. This has been found to be safe and effective and allows for delay of total knee replacement. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of hyaluronan were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis who failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has been diagnosed with bilateral knee osteoarthritis, worse on the right. She has undergone two prior viscosupplementation injections with long-term pain reduction documented and ability to avoid surgery. She has failed to respond to other conservative treatment. Therefore, the requested Synvisc One injections for both knees would be considered medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. In addition, there is support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, as this case. Therefore, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.

Answer: Initially the patient had many symptoms that resulted in her admission, however, subsequently, she appeared to stabilize.

Context: Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, residential treatment center services, on the dates at issue, were not medically necessary for treatment of the patients behavioral health conditions. Initially the patient had many symptoms that resulted in her admission, however, subsequently, she appeared to stabilize. Medications continue to be adjusted, however, none of the medication adjustments required treatment at the level of residential care. All told, the patient did not require 24 hour supervision for psychiatric treatment. There was no reasonable expectation that the patients symptoms or level of functioning would have significantly improved with residential care. Given the above, the services at issue were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested bilateral sacroiliac (SI) joint fusion surgery for treatment of her medical condition.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral sacroiliac (SI) joint fusion surgery for treatment of her medical condition. Findings:  Three physician reviewers found that bilateral sacroiliac joint fusion surgery is not likely to be more beneficial for treatment of her medical condition than any available standard therapy. In this case, the patient has not had a complete SI exam. Local SI tenderness is not diagnostic of SI joint disease, nor is a single finding as a positive thrust test confirmatory of SI joint disease. There is a lack of confirmatory evidence that she has SI joint pain or that the SI joint is her pain generator. Moreover, there is a lack of large, prospective, randomized, scientific, studies that have shown the long term safety and effectiveness of SI fusion for chronic degenerative disease of the SI joint. Thus, the proposed surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested magnetic resonance imaging (MRI) of the right knee and knee surgery for evaluation and treatment of the enrollees medical condition.

Answer: This patient presents with a fairly recent onset of right knee pain and swelling. The clinical exam findings show a range of motion greater than 90 degrees, mild effusion, and medial joint line tenderness.

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the right knee and knee surgery for evaluation and treatment of the enrollees medical condition. Findings: The physician reviewer found that an MRI is supported if additional imaging is necessary or internal derangement is suspected. The American College of Radiology imaging criteria for non-traumatic knee pain state that the initial imaging examination for non-traumatic knee pain is radiography. An MRI examination for non-traumatic knee pain is indicated when the pain is persistent and conventional radiographs are non-diagnostic or when additional information is necessary before instituting treatment. Therefore, in this patient, the MRI is medically necessary as adjunctive diagnostically and potentially to affect treatment.  Regarding the requested knee surgery, the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for knee osteoarthritis generally recommend conservative treatment of osteoarthritis of the knee including weight loss for patients with body mass index greater than or equal to 25, self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engaging in physical activity consistent with national guidelines. The AAOS does not recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.  Peer-reviewed evidence based medical guidelines do not support arthroscopic surgical treatment of knee osteoarthritis and support knee joint replacement for select patients with severe osteoarthritis failing conservative treatment. This patient presents with a fairly recent onset of right knee pain and swelling. The clinical exam findings show a range of motion greater than 90 degrees, mild effusion, and medial joint line tenderness. However, the specific surgical procedure has not been identified in detail. Therefore, the requested right knee surgery is not considered medically necessary.  All told, the medical records demonstrate the medical necessity of an MRI for more definitive evaluation of this patients medical condition; but, the medical records do not support the medical necessity for knee surgery.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Specifically, an MRI of the right knee is medically necessary. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested Provigil (modafinil) for treatment of her condition.

Context: Nature of Statutory Criteria/Case Summary:   An enrollee has requested Provigil (modafinil) for treatment of her condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the medical necessity for the requested medication has not been established. There is a lack of a documentation describing the patients degree of fatigue, consequences of fatigue, contributing factors to the fatigue, previous therapeutic trials, and current status of the MS. Given the lack of information provided for review, modafinil is not medically necessary. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested the LINX Anti-Reflux procedure for the treatment of his medical condition.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested the LINX Anti-Reflux procedure for the treatment of his medical condition.  Findings:  Three physician reviewers found that the LINX Reflux Management System has been approved for lower esophageal sphincter augmentation.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Results from early studies are encouraging.  However, at this time, the data for the LINX procedure is from observational data and not from high-quality randomized controlled trials.  There is a lack of controlled data comparing the LINX procedure to a standard reflux operation, Nissen fundoplication.  All told, the LINX Anti-Reflux procedure is not likely to be more efficacious than other treatment options.  Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested Afirma Gene Expression Classifier testing for evaluation of her medical condition.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested Afirma Gene Expression Classifier testing for evaluation of her medical condition.   Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, the services at issue were likely to have been of greater benefit than other modalities for evaluating this patient.   Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).  Findings: The physician reviewer found that according to the guidelines all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest recommendation (Rating: Class I, Level A) for treatment of HCV patients with this patients characteristics. Per the literature, in patients with viral loads less than 6 million IU/mL `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.` For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus.

Context: Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus.  Findings:  The physian reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. Per guidelines, treatment-naive genotype 3 patients should be treated with one of three regimens: Sovaldi/Daklinza for 12 weeks, Sovaldi/ribavirin with peginterferon for 12 weeks, or Sovaldi/ribavirin for 24 weeks.  Harvoni is not U.S. Food and Drug Administration (FDA) approved for treatment of genotype 3 and is not recommended by the guidelines, which note that the ELECTRON-II trial showed 64% cure rate with the requested regimen of Harvoni for 12 weeks. The activity of ledipasvir (part of Harvoni) against genotype 3 hepatitis C has been shown to be weak.  Although treatment is indicated in this case, and AASLD guidelines cite data showing increased survival with earlier treatment, alternatives for safe and effective therapy are available and recommended by AASLD. For these reasons, the requested treatment with Harvoni for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested magnetic resonance imaging (MRI) of the left breast for evaluation of her medical condition.

Answer: This patient has had stable mammograms

Answer: This patient reports severe discomfort in her left breast.

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the left breast for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In the last several years, there has been significant growth in the use of breast MRI.  Breast MRI has an important role in both screening and diagnostic settings.  However, from a screening perspective, there is no indication that this patient meets the criteria for being at high-risk for developing breast cancer, as defined as having a 20-25% likelihood of developing the disease.  MRI studies of the breast are highly sensitive but have a relatively low level of specificity.  The literature consistently does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  This patient has had stable mammograms, which is probably the best indication that she does not have tumor.  The most valuable tool in interpreting a mammogram is a comparison with an older mammogram, especially when there are no palpable masses.  There is a lack of evidence supporting the use of MRI as a surveillance tool rather than conventional mammography.  This patient reports severe discomfort in her left breast.  Breast pain is rarely associated with breast cancer, especially without a recognizable mass.  In this patients case, there is no reason to doubt the accuracy of the mammogram.  In conclusion, there is there is insufficient data to support the requested services in this patients case.  All told, the requested MRI of the left breast is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested sling procedure surgery for treatment of her urinary stress incontinence.

Answer: The urodynamic study did not reveal detrusor overactivity or leak with stress/urgency. The study suggests a high post void residual along with no detrusor function.

Context: Nature of Statutory Criteria/Case Summary:   An enrollee has requested sling procedure surgery for treatment of her urinary stress incontinence.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested surgery. There is lack of documentation submitted for review supporting a diagnosis of stress urinary incontinence. The urodynamic study did not reveal detrusor overactivity or leak with stress/urgency. The study suggests a high post void residual along with no detrusor function. This could be suggestive of overflow urinary incontinence with urinary retention and placement of a sling will increase outflow resistance leading to urinary obstruction. Moreover, the European Association of Urology (EAU) guidelines on urinary incontinence state, In clinical practice, it is a convention that non-surgical therapies are tried first because they usually carry the least risk of harm. They are often used in combination which makes it difficult to determine which components are effective. Per EAU guidelines conservative therapies include simple clinical intervention, behavior and physical therapies, lifestyle intervention and pharmacologic management. In this case, other than Vesicare which was noted to be helpful, there is lack of evidence showing the patient has tried and failed conservative therapy such as physical therapy. Based on the clinical documentation submitted, the sling procedure surgery is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.

Context: Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the use of breast tomosynthesis compared to conventional mammogram due to improved cancer detection rate. 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. Based on the medical literature cited above, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result:  Two rteviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.  Two physician reviewers found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to standard two dimensional (2D) mammography. The addition of three dimensional (3D) breast tomosynthesis allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue. Moreover, 3D breast tomosynthesis has been shown to improve patient outcomes in this clinical setting. Thus, 3D breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result:  Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested Viekira Pak and ribavirin for 12 weeks for treatment of her hepatitis C virus.

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak and ribavirin for 12 weeks for treatment of her hepatitis C virus. Three physician reviewers found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. For treatment-naive patients, therapy is recommended with Viekira Pak for 12 weeks (Class I, Level A recommendation). Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, treatment with Viekira Pak and weight-based ribavirin for 12 weeks is medically necessary in this patients case. Final Result: Three reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee requested a power seat elevator for her power wheelchair for treatment of the enrollee, who has a history of a spinal cord injury.

Answer: with power seat elevation, the patient would be able to adjust the seat of her wheelchair to be level with the transfer surface, to perform a level surface transfer independently with a sliding board.

Context: Nature of Statutory Criteria/Case Summary: An enrollee requested a power seat elevator for her power wheelchair for treatment of the enrollee, who has a history of a spinal cord injury. Findings:  The physician reviewer found that with power seat elevation, the patient would be able to adjust the seat of her wheelchair to be level with the transfer surface, to perform a level surface transfer independently with a sliding board.  Therefore, the power seat elevation feature is needed in this patients case.  This recommendation is consistent with the current standard of care in the field of rehabilitation medicine.  Customized power mobility equipment to allow independence with transfers is an appropriate practice in rehabilitation.  Because power seat elevation significantly facilitates transfers and promotes independence in this patients case, the requested power seat elevator for her power wheelchair is medically indicated. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested Harvoni for three months for treatment of his chronic hepatitis C virus genotype 1b.

Answer: The Health Plan has approved Viekira Pak with ribavirin.

Answer: However, this patients provider has recommended Harvoni to avoid use of ribavirin

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for three months for treatment of his chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that since this patient is genotype 1b, as per the data from the clinical trials and American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, Viekira Pak should be used alone and the addition of ribavirin is not recommended. The Health Plan has approved Viekira Pak with ribavirin. Viekira Pak and Harvoni are both considered first-line therapies with similar patient outcomes in terms of sustained virologic response. However, this patients provider has recommended Harvoni to avoid use of ribavirin. For these reasons, the requested Harvoni is medically necessary for treatment of this patients hepatitis C virus genotype 1b infection. Final Result:  Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: A female enrollee requested Harvoni for medical treatment of her hepatitis C.

Context: A female enrollee requested Harvoni for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases and Infectious Diseases Society of America noted the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  Initiation of treatment may avoid untoward complications from advanced disease, including liver failure, hepatocellular carcinoma and extrahepatic complications from hepatitis C.  Therefore, Harvoni is medically indicated for the treatment of this patient.

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


Answer: A male enrollee requested Harvoni for medical treatment of his hepatitis C.

Answer: the patient has minimal to no fibrosis.  This is despite having been infected with hepatitis C for many years.

Context: A male enrollee requested Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that based on the information provided, which includes two non-invasive assessments of liver fibrosis, the patient has minimal to no fibrosis.  This is despite having been infected with hepatitis C for many years.  He is unlikely to gain meaningful benefit from eradication of hepatitis C, and his prognosis is excellent.  This patient should have significant fibrosis in order to warrant treatment with Harvoni.  In this clinical setting, longitudinal assessments via noninvasive measures of fibrosis are medically appropriate.  All told, Harvoni is not medically indicated for the treatment of this patient.

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


Answer: A female enrollee requested residential treatment center services for treatment of her behavioral health condition.

Context: A female enrollee requested residential treatment center services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the request for residential treatment services is not medically necessary for treatment of the patients medical condition. In reviewing the records of this case, partial hospitalization services provided previously were safe, appropriate and adequately addressing the patients needs. Thus, there is no evidence that the patient has failed a less restrictive treatment setting. Further, since there were no clinical assessments provided, making the patients current status unknown, it is not possible to assert that a higher level of care is indicated.  Therefore, residential treatment center services are not medically necessary for treatment of the patients medical condition.

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


Answer: A 52-year-old female enrollee has requested ziv-aflibercept (Zaltrap) for treatment of her recurrent ovarian cancer.

Answer: this is a heavily treated patient with recurrent ovarian cancer. She has already received numerous chemotherapy off-label regimens since she has exhausted the standard options

Context: A 52-year-old female enrollee has requested ziv-aflibercept (Zaltrap) for treatment of her recurrent ovarian cancer.  Findings:  Two physician reviewers found that this is a heavily treated patient with recurrent ovarian cancer. She has already received numerous chemotherapy off-label regimens since she has exhausted the standard options (National Institutes of Health). Zaltrap has been used off-label in ovarian cancer. There are phase II data that demonstrate efficacy with limited toxicity especially in the resolution of malignancy ascites. Based on this medical evidence, it is medically appropriate to treat this patient with Zaltrap. Thus, the Zaltrap provided from the time period specified and forward was and is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.

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


Answer: A 50-year-old female enrollee requested revision of the gastric sleeve for medical treatment of her gastritis, gastroesophageal reflux disease (GERD), hypertension, and sleep apnea.

Context: A 50-year-old female enrollee requested revision of the gastric sleeve for medical treatment of her gastritis, gastroesophageal reflux disease (GERD), hypertension, and sleep apnea.   Findings:  The physician reviewer found that some patients do fail to lose or maintain weight loss following sleeve gastrectomy. Based on the documentation provided, it is not clear that this patient has been compliant with diet and activity requirements following surgery. Overall, the patient specific causes that might lead to a failure of a second operation with durable weight loss have not been addressed. Given the absence of a more thorough assessment and documentation of compliance with a diet and exercise regimen, the requested revision of the gastric sleeve is not supported as medically necessary for treatment of this patients medical condition.

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


Answer: The parent of a six-year-old male enrollee has requested somatropin (Genotropin) growth hormone for treatment of the enrollees idiopathic short stature.

Answer: this patient has short stature but normal growth velocity, normal growth factors, and a normal response to provocative GH testing. There is no known morphological abnormality of the pituitary gland or midline structures.

Context: The parent of a six-year-old male enrollee has requested somatropin (Genotropin) growth hormone for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that based on the available medical records, this patient has short stature but normal growth velocity, normal growth factors, and a normal response to provocative GH testing. There is no known morphological abnormality of the pituitary gland or midline structures. Given his age, it is too early to make a prediction of final adult height. It is difficult to distinguish whether the patients short stature and delayed bone age are due to constitutional delay or occult systemic disease. According to the Lawson Wilkins Pediatric Endocrinology Society recent guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than the 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient satisfies only two of these criteria, and no information is provided to document that all other systemic and nutritional causes of short stature have been ruled out. All told, there is inadequate evidence to support the medical necessity of Genotropin GH treatment for treatment of this patients short stature.

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


Answer: A 62-year-old male enrollee has requested a power wheelchair for treatment of his medical condition.

Answer: In this case, the patient was assessed by a physical therapist who noted that his mobility issues could be addressed with a front-wheeled walker.

Answer: The patient has some mobility impairments, but the records indicate that he is a household ambulator.

Answer: he has chronic health conditions, such as hyperlipidemia and hypertension

Context: A 62-year-old male enrollee has requested a power wheelchair for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Powered mobility prescriptions are best completed using a multidisciplinary approach, in order to optimize the appropriateness of the device.  In this case, the patient was assessed by a physical therapist who noted that his mobility issues could be addressed with a front-wheeled walker.  He could also use a manual wheelchair, if needed.  The patient has some mobility impairments, but the records indicate that he is a household ambulator.  Additionally, he has chronic health conditions, such as hyperlipidemia and hypertension, and would benefit from increased physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits use over power wheelchair use for persons with mobility impairments.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient.

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


Answer: A 56-year-old female enrollee requested sacroiliac fusion for medical treatment of her sacroiliac joint dysfunction.

Answer: This patient has received physical therapy, medication therapy, has sustained activity modification, and received sacroiliac joint injections, with no lasting relief.

Context: A 56-year-old female enrollee requested sacroiliac fusion for medical treatment of her sacroiliac joint dysfunction. Findings:  Two physician reviewers found that the clinical information submitted for review provided substantial evidence that lower levels of care intended to treat the patients sacroiliac joint dysfunction have failed to resolve her symptoms.  Per the current medical evidence, when nonoperative treatment fails, sacroiliac joint fusion may be appropriate.  This patient has received physical therapy, medication therapy, has sustained activity modification, and received sacroiliac joint injections, with no lasting relief.  In this patients case, proceeding with surgical intervention is warranted.  All told, the requested sacroiliac fusion is likely to be more effective than other treatment options.

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


Answer: A 62-year-old female enrollee genetic testing (Foundation One) for medical evaluation of her lung cancer.

Context: A 62-year-old female enrollee genetic testing (Foundation One) for medical evaluation of her lung cancer.  Findings:  Two physician reviewers found that according to the NCCN guidelines, the Panel strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. In this case, it was under these circumstances that the Foundation One assay was ordered, and as such, its use was consistent with current standards of care and was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.

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


Answer: A 25-year-old male enrollee requested rituximab (Rituxan) infusion for treatment of his Crohns disease and autonomic neuropathy.

Answer: This patient is suspected to have autonomic neuropathy, and has a history of Crohns disease, which is an autoimmune condition. Treatment directed at Crohns has thus far not helped the patients autonomic symptoms.

Context: A 25-year-old male enrollee requested rituximab (Rituxan) infusion for treatment of his Crohns disease and autonomic neuropathy.  Findings:  Two physician reviewers found that based on the current peer-reviewed medical literature, the requested Rituxan is not likely to provide this patient with an improved health outcome beyond that expected with standard available therapies. This patient is suspected to have autonomic neuropathy, and has a history of Crohns disease, which is an autoimmune condition. Treatment directed at Crohns has thus far not helped the patients autonomic symptoms. Rituxan has been shown of potential benefit with treatment of conditions such as chronic inflammatory demyelinating polyneuropathy (CIDP), multiple sclerosis, and myasthenia gravis. Data regarding treatment of Crohns disease with Rituxan is mixed, with some patients experiencing an exacerbation with treatment. Rituxan has also been associated with the development of progressive multifocal leukoencephalopathy. All told, the request for Rituxan is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.

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


Answer: A 21-year-old male enrollee requested 131I- metaiodobenzylguanidine (MIBG) targeted radiation therapy for treatment of his recurrent neuroblastoma.

Context: A 21-year-old male enrollee requested 131I- metaiodobenzylguanidine (MIBG) targeted radiation therapy for treatment of his recurrent neuroblastoma.  Findings:  Three physician reviewers found that neuroblastoma is a malignancy of childhood, with 90% of diagnoses occurring in children younger than five years of age. When diagnosed in adolescents and young adults it is often characterized by a prolonged course with use of chemotherapy. Because of the relative rarity of the disease, there are no large randomized trials that provide high-grade evidence on the most effective treatments. The available evidence indicates that radioactive MIBG is an efficacious agent, with response rates in various studies ranging from 0% to 75%. However, in this case, the patient has already responded to the treatment modality requested which provides a reasonable expectation that the treatment would work if administered again. All told, I131-MIBG targeted radiation therapy is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.

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


Answer: A 48-year-old female enrollee has requested a laparoscopic hysterectomy for treatment of her menorrhagia.

Context: A 48-year-old female enrollee has requested a laparoscopic hysterectomy for treatment of her menorrhagia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There are many medical and surgical alternatives to hysterectomy for the management of abnormal bleeding and painful periods.  These include oral contraceptives used for non-contraceptive reasons, as well as Mirena intrauterine device.   Non-contraceptive progestins can also be used.  There is a non-hormonal treatment, tranexamic acid, which is an antifibrinolytic agent that significantly reduces heavy periods when taken orally at the time of menses.  In addition, nonsteroidal anti-inflammatory drugs can be prescribed for heavy flow and menstrual cramps.  If hormonal treatments fail to control the problem, endometrial ablation is an appropriate alternative, with less morbidity than a hysterectomy.  This patient has had an incomplete evaluation of her abnormal bleeding, with an insufficient work-up to evaluate for other etiologies for her abnormal bleeding.  Per the submitted documentation, there is no record of a complete blood count, thyroid screening, or cervical cancer screening.  Various hormonal and endometrial causes for abnormal bleeding exist, and these require blood work and endometrial sampling by biopsy or dilation and curettage to assess.  All told, the requested laparoscopic hysterectomy is not medically indicated for the treatment of this patient.

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


Answer: A 67-year-old female enrollee requested a single photon emission computed tomography (SPECT) scan for medical evaluation of her medical condition.

Context: A 67-year-old female enrollee requested a single photon emission computed tomography (SPECT) scan for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the services at issue were not likely to have been more effective than other available modalities.  Per the submitted documentation, the available blood and imaging records gave no indication for advanced liver disease or tumor.  Contemporary measurement of liver fibrosis is made serologically and/or by elastography.  The systematic review and meta-analysis by Singh and colleagues noted that the degree of liver stiffness, using elastography, can predict outcomes in patients with chronic liver diseases.  Per the authors, liver stiffness measurement may be used in risk stratification.  Thus, the superior efficacy of SPECT scan has not been established.

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


Answer: A 51-year-old female enrollee requested a brain positron emission tomography (PET) scan for medical evaluation of her neurodegenerative condition.

Context: A 51-year-old female enrollee requested a brain positron emission tomography (PET) scan for medical evaluation of her neurodegenerative condition.   Findings:  Two physician reviewers found that in the medical literature, Claassen and colleagues reported that PET and 3-dimensional stereotactic surface projection  provide a useful diagnostic method to support a clinical diagnosis of primary lateral sclerosis. Studies with PET demonstrate predominant primary motor strip involvement. This pattern is illustrative of a stripe of hypometabolism. Thus, the literature does support the use of the requested PET for the evaluation of primary lateral sclerosis, looking for a stripe of hypometabolism. All told, the requested PET scan would be helpful to exclude primary lateral sclerosis in this patients condition.

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


Answer: A 57-year-old male enrollee requested the UroLift procedure for medical treatment of his benign prostatic hyperplasia.

Answer: A 57-year-old

Answer: This patient has been diagnosed with prostate cancer.

Context: A 57-year-old male enrollee requested the UroLift procedure for medical treatment of his benign prostatic hyperplasia.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other treatment options.  This patient has been diagnosed with prostate cancer.  However, the records do not document a repeat biopsy to determine if there has been any progression of disease.  Per the medical evidence, there is a lack of support for the UroLift procedure for patients with known prostate cancer.  At this time, long-term studies are needed to support the safety and efficacy of this procedure.  Thus, the requested UroLift procedure is not likely to be more effective than other available modalities.

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