Answer: The patient has requested authorization and coverage for oxycodone 5 mg.

Answer: The records document that this patient underwent a hip abscess drainage with uncomplicated post-operative course and was successfully transitioned from IV analgesics to oral oxycodone at discharge. The provider recommended

Answer: oral opioid medication to managed expected course of post-operative pain at discharge. After contacting the provider requesting additional refills, the provider recommended discontinuation of opioid therapy is not indicated based on his post-operative course and that transition to non-opioid analgesics is the best course of action.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone 5 mg. Findings:  The physician reviewer found that Centers for Disease Control and Prevention (CDC) guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and non-opioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Washington Agency Medical Directors Group Interagency guidelines state that providers should reserve opioids for acute pain resulting from severe injuries or medical conditions, surgical procedures, or when alternatives (non-opioid options) are ineffective or contraindicated. If opioids are prescribed, it should be at the lowest necessary dose and for the shortest duration (usually less than 14 days). The records document that this patient underwent a hip abscess drainage with uncomplicated post-operative course and was successfully transitioned from IV analgesics to oral oxycodone at discharge. The provider recommended an appropriate amount of oral opioid medication to managed expected course of post-operative pain at discharge. After contacting the provider requesting additional refills, the provider recommended discontinuation of opioid therapy is not indicated based on his post-operative course and that transition to non-opioid analgesics is the best course of action. For these reasons, the requested oxycodone 5 mg is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty 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: The patient has requested authorization and coverage for Ozempic 1 mg. The records provided for review document that this patient has a history of type 2 diabetes complicated by obesity. The patient has started treatment with Ozempic. The patients provider has recommended continued treatment with this medication.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ozempic 1 mg. The records provided for review document that this patient has a history of type 2 diabetes complicated by obesity. The patient has started treatment with Ozempic. The patients provider has recommended continued treatment with this medication. Although lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss (Gadde, et al.). There are currently multiple pharmacologic therapies which are available for weight management. Ozempic is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) agonists, which have been shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudsen and Lau). Multiple studies have demonstrated the efficacy of Ozempic in the promotion of weight loss, via reduced appetite and energy intake, and delayed gastric emptying (Cornell). All told, the requested Ozempic 1 mg is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested reimbursement for DecisionDx-Melanoma test.

Context: Findings:  The physician reviewer found that An enrollee has requested reimbursement for DecisionDx-Melanoma test. In reviewing the NCCN guidelines, the recommended therapy for patients with stage I cutaneous melanoma includes review of history, physical examination, and imaging to evaluate certain signs and symptoms. The NCCN indicates that category 1A treatment includes wide excision of the melanoma and consideration of sentinel lymph node biopsy. Furthermore, the NCCN guidelines state that for stage IB melanoma, the probability of a positive sentinel lymph node is greater than 10%. The NCCN guidelines do not endorse use of a gene expression assay to determine the course of treatment for patients with stage I melanoma. Marchetti and colleagues concluded that the prognostic ability of gene expression profiling tests among patients with localized melanoma have been found to be poor at correctly identifying recurrence in patients with stage I disease, suggesting limited potential for clinical utility in these patients. Given these findings, the DecisionDx-Melanoma test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.

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


Answer: The patient has requested reimbursement for general anesthesia services.

Answer: this patient required a surgical tooth extraction and she experienced substantial anxiety related to the procedure. The provider stated that the patient was had difficulty with anesthetizing in preparation for a simple procedure. The patient indicated that her provider recommended general anesthesia for the extraction.

Answer: The anesthesia record from 4/29/21 shows that the patient was given an ASA classification of 2.

Answer: the patients preoperative blood pressure was charted as 148/89

Context: Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for general anesthesia services. The American Dental Association (ADA) recommends moderate sedation for patients with American Society of Anesthesiologists (ASA) score of III or IV, and obesity, especially when associated with airway associated morbidity. The ADA also reports that deep sedation or general anesthesia may be appropriate for mentally or physically challenged patients. The American Academy of Pediatric Dentistry (AAPD) states that general anesthesia may be indicated for patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability;  patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy; the extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent; patients requiring significant surgical procedures;  patients for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk; and  patients requiring immediate, comprehensive oral/dental care (Cote, et al.). The records provided for review document that this patient required a surgical tooth extraction and she experienced substantial anxiety related to the procedure. The provider stated that the patient was had difficulty with anesthetizing in preparation for a simple procedure. The patient indicated that her provider recommended general anesthesia for the extraction. However, there is a lack of documentation that this patient has an anesthesia classification score ASA of 3 or 4, or evidence of a difficult airway. The anesthesia record from 4/29/21 shows that the patient was given an ASA classification of 2. The diagnosis of attention deficit disorder (ADD) is not considered a developmental disability that prevents a patient from undergoing a tooth extraction without sedation or general anesthesia. Moreover, the patients preoperative blood pressure was charted as 148/89, which does not constitute a hypertensive urgency or emergency. The providers records do not include sufficient documentation to support an indication for general anesthesia for the tooth extraction. Therefore, the general anesthesia services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty 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: The patients parent has requested authorization and coverage for intensive in-home family treatment.

Answer: The patient has a significant risk of harm, due to a history  multiple suicide attempts, and ongoing suicidal ideation and self-harm behaviors.

Answer: The documentation notes moderate functional impairment as evidenced by multiple visits to the emergency department and several inpatient hospitalizations, which has likely interfered with her schooling. The patient endorses depressive symptoms and is noted as being unable to function in the social setting.

Answer: The patient does not have comorbidities.

Answer: The patient has a moderately stressful environment as the patient had made allegations of abuse in the home resulting in investigation. The patient reports not having friends and being lonely. She has minimal coping skills and it appears that role expectations exceed the patients capacity to cope.

Answer: the records suggest that the patients parents may have difficulty setting appropriate limits for their daughter. The family has limited ability to respond appropriately to the patients developmental needs and/or problems, as the patients parents have declined various levels of care, indicating that they may not be consistently following treatment recommendations.

Answer: The patient has poor response to treatment and recovery management as prior treatment has included outpatient treatment including dialectical behavior therapy (DBT), multiple medication trials, intensive outpatient program (IOP), partial hospitalization program (PHP), crisis residential treatment, and at least two inpatient psychiatric hospitalizations.

Answer: The records suggest that the patient has refused to engage in recommended treatment in the past and struggles to utilize coping skills. She is noted as lacking motivation.

Context: Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for intensive in-home family treatment. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to a history  multiple suicide attempts, and ongoing suicidal ideation and self-harm behaviors. In terms of functional status, the records support a score of 3. The documentation notes moderate functional impairment as evidenced by multiple visits to the emergency department and several inpatient hospitalizations, which has likely interfered with her schooling. The patient endorses depressive symptoms and is noted as being unable to function in the social setting. With regard to comorbidity, the records support a score of 1. The patient does not have comorbidities. In terms of level of stress of the recovery environment, the records support a score of 3. The patient has a moderately stressful environment as the patient had made allegations of abuse in the home resulting in investigation. The patient reports not having friends and being lonely. She has minimal coping skills and it appears that role expectations exceed the patients capacity to cope. With regard to level of support of the recovery environment, the records support a score of 3 as the records suggest that the patients parents may have difficulty setting appropriate limits for their daughter. The family has limited ability to respond appropriately to the patients developmental needs and/or problems, as the patients parents have declined various levels of care, indicating that they may not be consistently following treatment recommendations. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management as prior treatment has included outpatient treatment including dialectical behavior therapy (DBT), multiple medication trials, intensive outpatient program (IOP), partial hospitalization program (PHP), crisis residential treatment, and at least two inpatient psychiatric hospitalizations. With regard to treatment acceptance and engagement, the records support a score of 3. The records suggest that the patient has refused to engage in recommended treatment in the past and struggles to utilize coping skills. She is noted as lacking motivation. Thus, the patient has a total score of 20. In this case, the recommended level of care is medically monitored community-based services. This is a higher level of care than the requested intensive in-home family treatment. In this patients case, intensive in-home family treatment is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, intensive in-home family treatment is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for Xifaxan 550 mg tablet (three tablets a day for 14 days). The records provided for review document that this patient has a history of inflammatory bowel syndrome, diarrhea predominant (IBS-D). The patients provider has recommended treatment with Xifaxan.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg tablet (three tablets a day for 14 days). The records provided for review document that this patient has a history of inflammatory bowel syndrome, diarrhea predominant (IBS-D). The patients provider has recommended treatment with Xifaxan. The U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of patients with IBS-D. In addition, Xifaxan has been demonstrated to be safe and effective in randomized placebo controlled clinical trials on the treatment of patients with IBS-D (Schoenfeld, et al.). In addition, the American College of Gastroenterology (ACG) guidelines for the treatment of IBS state that Xifaxan has been shown to be safe and effective for use in this patients clinical setting (Ford, et al.; Cangemi, et al.). The clinical trials and the FDA approval for Xifaxan in the treatment of IBS-D support the use of Xifaxan 550 mg three times daily for 14 days. For these reasons, the requested Xifaxan 550 mg tablet (three tablets a day for 14 days) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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: The patient has requested authorization and coverage for Taltz.

Answer: The medical records state that the patients psoriasis is well controlled while on Taltz.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Taltz. There is a lack of documentation regarding the extent of this patients psoriasis in terms of body surface area (BSA) involvement or prior disease severity to support an indication for treatment with Taltz. The medical records state that the patients psoriasis is well controlled while on Taltz. However, biologic medications including Taltz are not recommended for mild disease in the absence of extenuating factors such as difficult to treat areas. The U.S. Food and Drug Administration (FDA) has approved Taltz for the treatment of patients with moderate-to-severe plaque psoriasis, as defined by a BSA greater than 3%, or a psoriasis area and severity index (PASI) greater than 10 (Menter, et al.; Gordon, et al.). Similarly, the peer-reviewed medical literature recommends treatment with Taltz for patients with moderate-to-severe plaque psoriasis, which is not reported in the records provided for review. All told, the requested Taltz is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dermatology with subspecialty certification in dermatopathology 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 platelet rich plasma (PRP) treatment (CPT 0232T).

Answer: This patient is being treated for osteoarthritis of the left ankle. The patient previously underwent left ankle arthrodesis peroneus longus and brevis tenolysis in 2019 with hardware removal in 2021. The patient presents with continued complaints of foot pain that is persistent and noted to be in the heel rated at 4/10 in the posterior aspect. The provider noted that the patient has been treated with physical therapy. The provider has recommended treatment with PRP injections.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet rich plasma (PRP) treatment (CPT 0232T). Findings:  The physician reviewer found that This patient is being treated for osteoarthritis of the left ankle. The patient previously underwent left ankle arthrodesis peroneus longus and brevis tenolysis in 2019 with hardware removal in 2021. The patient presents with continued complaints of foot pain that is persistent and noted to be in the heel rated at 4/10 in the posterior aspect. The provider noted that the patient has been treated with physical therapy. The provider has recommended treatment with PRP injections. On review of the peer-reviewed medical literature, the data on PRP injections remains mixed with regard to efficacy in the treatment of patients with ankle arthritis. Fukawa and colleagues concluded that intra-articular PRP injections resulted in no serious adverse effects, while it reduced pain in the patients with ankle osteoarthritis. Paget and colleagues concluded among patients with ankle osteoarthritis, intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks. However, there is a paucity of large-scale, peer-reviewed literature demonstrating the long-term safety and efficacy of PRP injection in the treatment of patients with ankle osteoarthritis. For these reasons, the requested PRP treatment (CPT 0232T) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested PRP treatment (CPT 0232T) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The 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: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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: The patients parent has requested authorization and coverage for Motegrity (2 mg tablets, 30 tablets per 30 days).

Context: Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Motegrity (2 mg tablets, 30 tablets per 30 days). Motegrity is a medication that is U.S. Food and Drug Administration (FDA) approved for the treatment of motility in the gastrointestinal tract in patients 18 years of age and older. In an open-label pilot study, Motegrity demonstrated a favorable effect on stool frequency, stool consistency, and fecal incontinence frequency in children with functional constipation (Winter, et al.). However, in a multicenter randomized controlled clinical trial including 213 children with functional constipation, Motegrity was found to be less effective in increasing stool frequency and decreasing fecal incontinence frequency when compared to placebo (Mugie, et al.). Overall, there is a lack of data demonstrating the safety and efficacy of Motegrity in the pediatric patient population. Thus, Motegrity is not expected to decrease this patients likelihood of having obstructive symptoms. All told, the requested Motegrity (2 mg tablets, 30 tablets per 30 days) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certification in pediatric 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 myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided by M.D.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided by M.D. The American College of Cardiology guidelines on the appropriate indications for myocardial strain imaging include patients prior to and following exposure to potentially cardiotoxic agents or for patients with suspected hypertrophic cardiomyopathy. In this case, the records do not reflect that the patient meets either of these indications. Therefore, myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided by M.D., was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided M.D., at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 3 are internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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: The patients parent has requested authorization and coverage for weekly individual mental health therapy services.

Answer: The patient had some risk for harm due to passive suicidal ideation and mild substance use

Answer: The patient had moderate functional impairment, due to the presence of symptoms of depression, anxiety, and panic. The records noted that the patient still looked forward to some activities and saw some friends but had withdrawn socially.

Answer: The patient had minor comorbidity due to some substance use, depression, and anxiety.

Answer: The patient had a mildly stressful environment due to a stable home with a mother involved in her care but with the patient reporting some frustration and discomfort.

Answer: The patient had moderate or equivocal response to treatment as she appeared to have some response to therapy but continued to have symptoms.

Answer: The patient appears able to develop a trusting, positive relationship with clinicians and other care providers

Context: Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly individual mental health therapy services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. With regard to risk of harm, the records support a score of 2. The patient had some risk for harm due to passive suicidal ideation and mild substance use.In terms of functional status, the records support a score of 3. The patient had moderate functional impairment, due to the presence of symptoms of depression, anxiety, and panic. The records noted that the patient still looked forward to some activities and saw some friends but had withdrawn socially.  With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity due to some substance use, depression, and anxiety. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to a stable home with a mother involved in her care but with the patient reporting some frustration and discomfort. With regard to level of support of the recovery environment, the records support a score of 2 due to the patients mother participating in her care. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment as she appeared to have some response to therapy but continued to have symptoms. With regard to treatment acceptance and engagement, the records support a score of 2. The patient appears able to develop a trusting, positive relationship with clinicians and other care providers.Thus, the patient has a total score of 16. This is consistent with low intensity community-based services. In this patients case, weekly individual mental health therapy services are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, weekly individual mental health therapy services are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for durable medical equipment - Bioness L300 GO functional electric stimulator (FES) and supplies.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment - Bioness L300 GO functional electric stimulator (FES) and supplies. Findings:  The physician reviewer found that a lack of evidence in current medical literature demonstrating that exposure to lower limb orthotic devices employing functional electrical stimulation (FES) improves gait in persons with central neurological weakness. In a comprehensive review of the literature comparing FES-aided lower limb orthoses and conventional or mechanical orthoses, Johnston and colleagues reported that studies that directly compared ankle-foot orthotics (AFO) and FES did not indicate overall superiority of one over the other. The authors further noted that the evidence on AFO and FES improving gait kinematics was weak. While there are some potential benefits to exogenously stimulating lower limb effector muscles that have lost effective connections with the central nervous system, it is not evident that the potential benefits of FES-aided orthoses, such as a lighter weight and the potential of a decreased likelihood of skin breakdown, outweigh their disadvantages, such as a lack of stabilizing support during stance phase and potential for mechanical or technological complications including lead misapplication, lead failure or dislodgement, battery drainage or failure, and device failure. Given the lack of data supporting the use of the requested equipment as favorably altering neurological recovery, the requested equipment and supplies are not medically indicated. Therefore, durable medical equipment - Bioness L300 GO FES and supplies are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment and supplies are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for a consultation for proton beam radiation therapy.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a consultation for proton beam radiation therapy. The National Comprehensive Cancer Network (NCCN) guidelines on the treatment of breast cancer  do not endorse the routine use of proton therapy. Per the medical literature, there is a lack of clinical data suggesting that proton beam radiation therapy is associated with a clinical benefit in the treatment of breast cancer. In a majority of cases, an acceptable cardiac and lung dose may be achieved using intensity modulated radiation or three-dimensional conformal techniques, along with the use of deep inspiratory breath holds during treatment, moving the heart away from the chest wall. Therefore, a consultation for proton beam radiation therapy is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 radiation oncology 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 bilateral breast magnetic resonance imaging (MRI) with and without contrast (CPT 77049). This patient presents with a family history of breast cancer in her mother and maternal grandmother. The patients provider has recommended breast magnetic resonance imaging (MRI), given her family history and findings of microcalcifications in the right breast and two rounded asymmetries in the left breast.

Answer: This patient has one first-degree and one second-degree relative with breast cancer, making her high risk for developing breast cancer. The patients lifetime risk as estimated by a genetic counselor is high

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI) with and without contrast (CPT 77049). This patient presents with a family history of breast cancer in her mother and maternal grandmother. The patients provider has recommended breast magnetic resonance imaging (MRI), given her family history and findings of microcalcifications in the right breast and two rounded asymmetries in the left breast. The current peer-reviewed medical literature and guidelines recommend biopsy for a palpable breast mass, even in the setting of negative mammogram and ultrasound findings. However, MRI is indicated for the screening of high risk patients. This patient has one first-degree and one second-degree relative with breast cancer, making her high risk for developing breast cancer. The patients lifetime risk as estimated by a genetic counselor is high, which supports an indication for MRI screening as the appropriate modality. Based on these findings, the requested bilateral breast MRI with and without contrast (CPT 77049) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested bilateral breast MRI with and without contrast (CPT 77049) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in 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 hyaluronic acid injection

Answer: The patient has tried other conservative treatments, including corticosteroid injections, which provided little improvement. The alternative is a total knee arthroplasty in the presence of mild osteoarthritis.

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for hyaluronic acid injection.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried other conservative treatments, including corticosteroid injections, which provided little improvement. The alternative is a total knee arthroplasty in the presence of mild osteoarthritis. Therefore, the requested hyaluronic acid injection is medically necessary for the 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 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 authorization and coverage for cancer vaccine

Answer: This patient has advanced neuroblastoma.

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for cancer vaccine.Findings: Two out of three physician reviewers found that the requested cancer vaccine is not likely to be more beneficial for you than any available standard therapy.This patient has advanced neuroblastoma. There is insufficient evidence demonstrating the efficacy and safety of neuroblastoma vaccine for the treatment of advanced neuroblastoma. The current National Cancer Institute (NCI) guidelines do not support the use of a neuroblastoma vaccine as an accepted treatment option for advanced neuroblastoma. The current literature indicates that further studies are still needed to establish the efficacy and safety of the vaccine. Therefore, the requested cancer vaccine is not likely to be more beneficial than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in internal medicine with sub-specialty certification in medical oncology. All reviewers 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 authorization and coverage for Euflexxa injections in both knees (HCPCS code J7323)

Answer: In this case, there is a history of good extended response to prior viscosupplementation.

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

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Euflexxa injections in both knees (HCPCS code J7323).An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, there is a history of good extended response to prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being total knee arthroplasties. Therefore, Euflexxa injections in both knees (HCPCS code J7323) are 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 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 authorization and coverage for consultation with a transplant hepatologist and blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase (GGT), and prothrombin time (PT)).The patient has risk factors for metabolic liver disease, including prediabetes and elevated triglycerides.

Context: Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for consultation with a transplant hepatologist and blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase (GGT), and prothrombin time (PT)).The patient has risk factors for metabolic liver disease, including prediabetes and elevated triglycerides. According to Kwo and colleagues, a workup for underlying liver disease is appropriate given the risk of eventual cirrhosis with untreated metabolic liver disease, and the need to intervene on modifiable liver disease before the development of cirrhosis or end-stage liver disease. All of the requested blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase (GGT), and prothrombin time (PT)) are used in the assessment of liver disease, liver disease activity, hepatic function, or liver fibrosis level. However, the patient does not have an indication for consideration of liver transplantation, and there is no evidence of liver disease on extensive laboratory testing. For these reasons, the requested blood tests are medically necessary for the evaluation of the patients medical condition. However, the consultation with a transplant hepatologist is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that some of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in 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: The patients parent has requested authorization and coverage for Nutropin AQ.

Answer: In this case, the patient does not have a family history of constitutional delay of growth and pubertal development. The records document recent height below 2.25 standard deviations of the mean for age and gender in growth, without an identified cause for the poor growth.

Context: Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ. The U.S. Food and Drug Administration (FDA) approves the use of Nutropin for the treatment of idiopathic short stature (ISS) in pediatric patients. Grimberg and colleagues note that ISS is defined by a height standard deviation score of 2.25. In this case, the patient does not have a family history of constitutional delay of growth and pubertal development. The records document recent height below 2.25 standard deviations of the mean for age and gender in growth, without an identified cause for the poor growth. The patients recent growth pattern indicates that catch-up growth is unlikely without somatotropin (brand name Nutropin AQ) therapy. In this clinical setting, the requested medication is medically indicated. Therefore, Nutropin AQ is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: The enrollee requested reimbursement for the computed tomography (CT) scan of the maxillofacial/sinus.

Answer: In this case, the patient has a history of shortness of breath and fatigue as well as nasal symptoms. A CT scan was obtained to evaluate the sinuses for possible infection and surgery.

Context: Nature of Statutory Criteria/Case Summary: The enrollee requested reimbursement for the computed tomography (CT) scan of the maxillofacial/sinus. There is sufficient support for the services at issue in this clinical setting. CT scanning is the standard method of evaluating the sinuses. Moreover, Che and colleagues stated, Analyzing the CT features of bone changes in unilateral chronic maxillary sinusitis can improve the accuracy of disease diagnosis. In this case, the patient has a history of shortness of breath and fatigue as well as nasal symptoms. A CT scan was obtained to evaluate the sinuses for possible infection and surgery. Therefore, the CT scan of the maxillofacial/sinus was medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the service at issue was 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 otolaryngology 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 Repatha 140 mg/mL SureClick.The patient has established coronary artery disease and is status post coronary angioplasty. He has a strong family history of coronary artery disease

Answer: He had attempted combination therapy with atorvastatin/ezetimibe at highest doses, but his LDL level did not reach goal. Although rosuvastatin did get him to goal, it was not tolerated due to severe side effects. A reattempt at atorvastatin/ezetimibe

Answer: was unsuccessful. He was

Answer: prescribed Repatha, which lowered his LDL level to goal without side effects.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg/mL SureClick.The patient has established coronary artery disease and is status post coronary angioplasty. He has a strong family history of coronary artery disease and should be managed with intensive risk factor modification per American College of Cardiology/American Heart Association (ACC/AHA) guidelines. He had attempted combination therapy with atorvastatin/ezetimibe at highest doses, but his LDL level did not reach goal. Although rosuvastatin did get him to goal, it was not tolerated due to severe side effects. A reattempt at atorvastatin/ezetimibe, which would be the only other option to get him to goal along with lifestyle modifications, was unsuccessful. He was appropriately prescribed Repatha, which lowered his LDL level to goal without side effects. The patient meets published ACC/AHA guidelines for Repatha use. Therefore, Repatha 140 mg/mL SureClick is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: An enrollee has requested authorization and coverage Dexilant (dexlansoprazole) 60 mg delayed-release capsules.

Answer: In this case, the patient did not have sufficient control with multiple proton pump inhibitors, pantoprazole and omeprazole.

Answer: additional similar proton pump inhibitors have not been attempted

Answer: Dexilant, unlike alternatives, has been effective in this case.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage Dexilant (dexlansoprazole) 60 mg delayed-release capsules. Findings:  The physician reviewer found that gastroesophageal reflux disease (GERD) and esophagitis are at least partially caused by mechanical defects in esophageal motility. Scarpignato and colleagues indicate that since proton pump inhibitors (PPIs) do not correct the underlying pathophysiological motor abnormalities responsible for reflux, ongoing treatment at a sufficient dose is likely to be needed to maintain remission. Usai and colleagues state that insufficient acid suppression can result in complications of GERD, such as persistent erosive esophagitis, esophageal stricture, esophageal ring, and Barrett's esophagus. Comparison of proton pump inhibitors, including rabeprazole, omeprazole, lansoprazole, and pantoprazole, has found no significant difference in control and healing of gastroesophageal reflux disease. Dexilant, unlike all other proton pump inhibitors, is released in an extended fashion. This delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric pH than other proton pump inhibitors. In a study by Fass and colleagues, a significant majority of patients (88%) requiring other PPIs twice daily were able to control symptoms on Dexilant once daily. Dexilant is also more effective to treat heartburn than alternatives such as esomeprazole. American College of Gastroenterology guidelines for the treatment of GERD do recommend proton pump inhibitor therapy, especially in patients with complications such as esophagitis. In this case, the patient did not have sufficient control with multiple proton pump inhibitors, pantoprazole and omeprazole. Although additional similar proton pump inhibitors have not been attempted, they are unlikely to be effective after failure of omeprazole and pantoprazole. Dexilant, unlike alternatives, has been effective in this case. Therefore, Dexilant (dexlansoprazole) 60 mg delayed-release capsules are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested reimbursement and prospective authorization and coverage for inpatient care services at Providence St. Joseph Medical Center. In this case, the patient presented with gastroparesis and malnutrition. She had a gastrojejunostomy tube with appropriate placement confirmed on computed tomography (CT) scans, with stable neurologic and hemodynamic statuses. Her future treatment options included deep brain stimulation surgery. The patients chronic pain was managed with a medication regimen

Context: Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for inpatient care services at Providence St. Joseph Medical Center. In this case, the patient presented with gastroparesis and malnutrition. She had a gastrojejunostomy tube with appropriate placement confirmed on computed tomography (CT) scans, with stable neurologic and hemodynamic statuses. Her future treatment options included deep brain stimulation surgery. The patients chronic pain was managed with a medication regimen. Given that the patient was medically stable, without advanced procedures or monitoring, and without complications or unstable comorbidities, the services at issue were not and are not medically indicated. Therefore, inpatient care services at Providence St. Joseph Medical Center were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are 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 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 geniculate artery embolization of the right knee. This patient has a history of right knee pain with symptoms that have gradually worsened over time. Imaging revealed moderate osteoarthritis in the medial compartment and mild patellofemoral osteoarthritis. Treatment has included NSAIDs, physical therapy, steroid injections, and hyaluronic acid injections. The patient has expressed a desire to avoid surgery. His provider has recommended geniculate artery embolization.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for geniculate artery embolization of the right knee. This patient has a history of right knee pain with symptoms that have gradually worsened over time. Imaging revealed moderate osteoarthritis in the medial compartment and mild patellofemoral osteoarthritis. Treatment has included NSAIDs, physical therapy, steroid injections, and hyaluronic acid injections. The patient has expressed a desire to avoid surgery. His provider has recommended geniculate artery embolization. Researchers concluded that geniculate artery embolization is a safe and effective treatment approach for the management of recurrent hemarthrosis of the knee following arthroplasty and should be considered first-line treatment following failure of conservative management. Researchers reported that, Embolization of the geniculate arteries in our study was a safe and effective treatment of recurrent spontaneous hemarthrosis following total knee arthroplasty. However, there is a lack of large-scale, long-term studies documenting the safety and efficacy of the geniculate artery embolization outside of recurrent hemarthrosis post arthroplasty. This patients records do not document any prior knee arthroplasty to support an indication for geniculate artery embolization. Therefore, the requested geniculate artery embolization of the right knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested geniculate artery embolization of the right knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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 authorization and coverage for an otolaryngology office visit at a tertiary care facility

Answer: In this case, the patient presents with a significant speech delay. He had bilateral tubes placed in 2019. On late 2020, the patient had a vocabulary of 50 words. The plan was for the patient to return in three months. Per the submitted documentation, speech delay is the primary problem in this case.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an otolaryngology office visit at a tertiary care facility.At issue is whether the requested referral for an otolaryngology office visit at a tertiary care facility is medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.There is sufficient support for the requested services in this clinical setting. Audiometry follow-up and evaluation of the tympanic membrane after myringotomy and tube placement is part of the standard of care in caring for patients with tubes. In this case, the patient presents with a significant speech delay. He had bilateral tubes placed in 2019. On late 2020, the patient had a vocabulary of 50 words. The plan was for the patient to return in three months. Per the submitted documentation, speech delay is the primary problem in this case. A tertiary care facility is the most appropriate site for follow-up evaluation, which would include speech, audiology, otolaryngology, and pediatric neurology evaluations. Therefore, the requested otolaryngology office visit at a tertiary care facility is medically necessary to prevent disease, disability, and other health conditions or their progression.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 intraoperative radiation therapy (IORT) (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294).

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT) (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294). Accelerated partial breast irradiation (APBI) may be delivered using external beam radiotherapy, brachytherapy, or intraoperative radiation therapy (IORT). IORT to perform APBI is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria per current National Comprehensive Cancer Network (NCCN) guidelines. Researchers reported that at four-year follow-up, local control rates between IORT and external beam whole breast radiotherapy were largely equivalent. A study concluded that, Important radiation-related quality of life parameters after IORT were superior to external beam radiation therapy. Per the authors, toxicity may also be slightly improved with IORT. This patient meets ABPI criteria set by the American Society of Breast Surgeons (ASBS), given her age and the presence of a tumor measuring less than 3 cm. All told, the requested IORT (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested IORT (CPT codes 77300, 77424, 77470, 77469, 77336, 77263, 77280, and 19294) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation oncology 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 dual diagnosis residential substance misuse treatment

Answer: The patient had been sober from alcohol for 75 days

Answer: Records indicate that the patient had a history of cerebrovascular accidents with left sided weakness, hypertension and gastritis.

Answer: The patient was diagnosed with major depressive disorder and was suicidal upon admission. He experienced frequent suicidal ideation that was exacerbated by drinking. He had two prior attempts and was admitted for suicidal ideation on three days prior to his admission at the residential treatment center. He initially endorsed multiple symptoms of depression including hopelessness, worthlessness, anhedonia, depressed mood, poor sleep and appetite.

Answer: The patient was also assessed as not posing a risk to self or others.

Answer: The patient admitted himself voluntarily and participated actively in treatment. He recognized the effects of alcohol on his health and relationships. The patient acknowledged the existence of a substance use problem, and he recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change.

Answer: The patient had been drinking heavily for 30 years and most recently relapsed after he had three strokes. He made significant progress in addressing his relapse triggers, and he was actively working on transitioning to the community with the assistance of his daughter. He was not able to return to the camper that he was residing in due to his disability from the cerebrovascular accidents. The patient needed staff support to maintain engagement in his recovery program while transitioning to life in the community.

Answer: The patient had been technically homeless, as he was living alone in a camper and going from campsite to campsite. He was socially isolated and had been experiencing frequent bouts of suicidal ideation with severe depression. He had been unable to cope with his physical disabilities after having three strokes. He is not able to reside alone due to disabilities from his strokes.

Answer: the patient was noted to be able to identify triggers and coping skills. He was described as engaged, positive, focused and motivated, and he was described as having taken on a leadership role. His depressed mood had stabilized, and he no longer needed staff support to maintain engagement in his recovery program.

Answer: the patient was noted to have changed his mind regarding his original discharge plan, as he reconciled with his significant other and intends to move in with her rather than his daughter, which had been the patients earlier discharge plan.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for dual diagnosis residential substance misuse treatment.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient met Level 3.1 criteria for residential treatment center services provided during the first 25 days of the services at issue. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient had been sober from alcohol for 75 days, and he did not have a significant Prediction of Alcohol Withdrawal Severity Scale (PAWSS) score. The patients withdrawal needs could be met in a Level 3.1 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient had a history of cerebrovascular accidents with left sided weakness, hypertension and gastritis. The patients biomedical problems, if any, were stable.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient was diagnosed with major depressive disorder and was suicidal upon admission. He experienced frequent suicidal ideation that was exacerbated by drinking. He had two prior attempts and was admitted for suicidal ideation on three days prior to his admission at the residential treatment center. He initially endorsed multiple symptoms of depression including hopelessness, worthlessness, anhedonia, depressed mood, poor sleep and appetite. The patients mental status permitted participation. His psychiatric condition was stable and his anxiety and depression could be related to substance use problems or to a stable co-occurring emotional condition with imminent likelihood of relapse with dangerous consequences outside of a structured environment. The patient was also assessed as not posing a risk to self or others.For dimension 4 - Readiness to Change. The patient admitted himself voluntarily and participated actively in treatment. He recognized the effects of alcohol on his health and relationships. The patient acknowledged the existence of a substance use problem, and he recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.For dimension 5 - Relapse, Continued use, or Continued Problem Potential. The patient had been drinking heavily for 30 years and most recently relapsed after he had three strokes. He made significant progress in addressing his relapse triggers, and he was actively working on transitioning to the community with the assistance of his daughter. He was not able to return to the camper that he was residing in due to his disability from the cerebrovascular accidents. The patient needed staff support to maintain engagement in his recovery program while transitioning to life in the community.For dimension 6 - Recovery Environment. The patient had been technically homeless, as he was living alone in a camper and going from campsite to campsite. He was socially isolated and had been experiencing frequent bouts of suicidal ideation with severe depression. He had been unable to cope with his physical disabilities after having three strokes. He is not able to reside alone due to disabilities from his strokes. The patient is able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue clinical, vocational, educational, and community activities. Continued exposure to his living environment, however, made recovery unlikely, and the patient had insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment.Using the ASAM level 3.1 criteria worksheet, the patient met all six criteria for medical necessity and therefore qualified for ASAM Level 3.1 treatment during the first 25 days of the services at issue. Accordingly, the dual diagnosis residential substance misuse treatment provided during the first 25 days of the services at issue was medically necessary to treat the patients condition.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient did not meet Level 3.1 criteria for residential treatment center services provided during the next 29 days of the services at issue. Regarding dimension 5 - Relapse, Continued use, or Continued Problem Potential  during this period, the patient was noted to be able to identify triggers and coping skills. He was described as engaged, positive, focused and motivated, and he was described as having taken on a leadership role. His depressed mood had stabilized, and he no longer needed staff support to maintain engagement in his recovery program. Given these status changes, the patient no longer met the dimension 5 criteria for Level 3.1. Regarding dimension 6 - Recovery Environment - the patient was noted to have changed his mind regarding his original discharge plan, as he reconciled with his significant other and intends to move in with her rather than his daughter, which had been the patients earlier discharge plan. Given these status changes, the patient no longer met the dimension 6 criteria for Level 3.1. Accordingly, the dual diagnosis residential substance misuse treatment provided during the next 29 days of the services at issue was not medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were partially medically necessary to treat the patient's condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: The patient has requested authorization and coverage for physical therapy. This patient with cervical radiculopathy has experienced persistent neck pain and other symptoms including headaches and dizziness. She reported some symptomatic improvement and range of motion improvement with formal physical therapy.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. This patient with cervical radiculopathy has experienced persistent neck pain and other symptoms including headaches and dizziness. She reported some symptomatic improvement and range of motion improvement with formal physical therapy. There is a paucity of high-quality evidence informing treatment for cervical radiculopathy, including the efficacy of exercise and physical therapy interventions such as manual therapy and traction. Current treatment guidelines related to the management of cervical radiculopathy are lacking, while higher quality studies are underway. There is a lack of high grade, evidence-based support for prolonged formal physical therapy in this clinical setting. Treatment should include services in the formal therapy setting until transition to an independent program can be made. However, there is a lack of an indication in the available records that this patient has impairments that preclude full transition to an independent program with exercises and modalities that can be applied independently for further improvement in range of motion and symptomatic management. There is no reasonable expectation that her clinical course or outcomes with further formal therapy would be marginally improved over an independent program. The patients documented exercises in the formal therapy setting can be performed independently or substituted with independent exercise. For palliation, the patient can use topical heat, self-massage techniques, and independently applied electrical stimulation pads. All told, the requested physical therapy is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 authorization and coverage for Laparoscopic Sleeve Gastrectomy

Answer: In this case, the patient has been documented to have both severe obesity with a BMI of 35 kg/m2 and the co-morbid condition of hypertension. The patient is noted to have been obese and struggling with weight since childhood, and she has a long-term history of prior weight loss efforts that have not been successful in maintaining any significant weight loss. Records document that the patient has also successfully completed a standard multidisciplinary evaluation.

Context: Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Laparoscopic Sleeve Gastrectomy.Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity (Mechanick, J., et al.). Mechanick and associates have developed updated clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues. These guidelines recommend that all patients should undergo a psychosocial-behavioral evaluation as well as an appropriate nutritional evaluation before any bariatric surgical procedure. In this case, the patient has been documented to have both severe obesity with a BMI of 35 kg/m2 and the co-morbid condition of hypertension. The patient is noted to have been obese and struggling with weight since childhood, and she has a long-term history of prior weight loss efforts that have not been successful in maintaining any significant weight loss. Records document that the patient has also successfully completed a standard multidisciplinary evaluation. Under these circumstances, the requested Laparoscopic Sleeve Gastrectomy is medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for this patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: The patient has requested authorization and coverage for Xifaxan.

Answer: In this case, the patient has diagnoses of IBS with constipation and SIBO.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan. A study notes that rifaximin treatment appears effective and safe for the treatment of small intestine bacterial overgrowth (SIBO). Another study found that rifaximin effectively normalized the glucose hydrogen breath test (GHBT) and reduced the symptoms of irritable bowel syndrome (IBS) by possibly counteracting SIBO. An additional study notes that rifaximin plus neomycin is superior to neomycin alone in improving multiple constipation-predominant IBS symptoms. In this case, the patient has diagnoses of IBS with constipation and SIBO. While antibiotics such as fluoroquinolones may address bacterial overgrowth, they would not be expected to improve irritable bowel syndrome. Given the current medical literature, the requested medication is medically indicated in this clinical setting. Therefore, Xifaxan 550 mg tablets is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) for a minimum of 90 days.

Answer: the patient was admitted to RTC after completing a 10-day detoxification at a different facility. She continued to have withdrawal symptoms including agitation, anxiety, hallucinations, and gastrointestinal upset.

Answer: the patient does not have any medical problems. The patients biomedical problems were stable and did not require medical or nurse monitoring.

Answer: the patient has significant difficulties with acute PTSD, anxiety, and an eating disorder. She participated in groups and was described by the providers as constantly anxious. The patients mental status was assessed as sufficiently stable to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients psychiatric condition was stable, and he was assessed as having minimal problems in this area as evidenced by anxiety that may be related to substance abuse problems with imminent likelihood of relapse outside of structured environment. In addition, the patient was assessed as not posing a risk of harm to self or others.

Answer: the patient admitted herself for treatment after a four-day binge on methamphetamine and experiencing a psychotic episode that resulted in her arrest. She has tried on several occasions to stop using alcohol and Xanax and has been unable to do so despite negative consequences. She expressed a desire to remain clean and abstinent and was able to identify negative consequences of her addiction. The patient acknowledged the existence of a psychiatric condition and substance use problem. She recognized specific negative consequences and dysfunctional behaviors and their effect on her desire to change.

Answer: the patient endorsed drinking alcohol in combination with Xanax for several years. She is also on 16 mg of suboxone daily. She started using methamphetamine and experienced psychotic episodes with dangerous behaviors. She also used methamphetamine on the day between her 10-day detoxification and admission to the RTC. The patient demonstrated limited coping skills to address relapse triggers and urges.

Answer: the patient was living with her boyfriend who also uses substances, and she was unable to return to that apartment. She was unemployed due to her substance usage and she had difficulty accepting responsibility for her actions. The patient was able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) for a minimum of 90 days. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient was admitted to RTC after completing a 10-day detoxification at a different facility. She continued to have withdrawal symptoms including agitation, anxiety, hallucinations, and gastrointestinal upset. The patients withdrawal needs could have been safely managed in Level 3.1 setting. For dimension 2, the patient does not have any medical problems. The patients biomedical problems were stable and did not require medical or nurse monitoring. For dimension 3, the patient has significant difficulties with acute PTSD, anxiety, and an eating disorder. She participated in groups and was described by the providers as constantly anxious. The patients mental status was assessed as sufficiently stable to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients psychiatric condition was stable, and he was assessed as having minimal problems in this area as evidenced by anxiety that may be related to substance abuse problems with imminent likelihood of relapse outside of structured environment. In addition, the patient was assessed as not posing a risk of harm to self or others. For dimension 4, the patient admitted herself for treatment after a four-day binge on methamphetamine and experiencing a psychotic episode that resulted in her arrest. She has tried on several occasions to stop using alcohol and Xanax and has been unable to do so despite negative consequences. She expressed a desire to remain clean and abstinent and was able to identify negative consequences of her addiction. The patient acknowledged the existence of a psychiatric condition and substance use problem. She recognized specific negative consequences and dysfunctional behaviors and their effect on her desire to change. She was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient endorsed drinking alcohol in combination with Xanax for several years. She is also on 16 mg of suboxone daily. She started using methamphetamine and experienced psychotic episodes with dangerous behaviors. She also used methamphetamine on the day between her 10-day detoxification and admission to the RTC. The patient demonstrated limited coping skills to address relapse triggers and urges. She was in imminent danger of relapse with dangerous consequences and needs 24-hour structure to help her apply recovery and coping skills. For dimension 6, the patient was living with her boyfriend who also uses substances, and she was unable to return to that apartment. She was unemployed due to her substance usage and she had difficulty accepting responsibility for her actions. The patient was able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Continued exposure to the patients living environment made recovery unlikely and the patient had insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC services, for a total treatment plan of a minimum of 90 days were and are medically necessary for this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: The patient has requested authorization and coverage for positron emission tomography (PET) scan.

Answer: this patient was diagnosed with triple negative breast cancer in 2014 with recurrence in 2018. A PET scan showed activity in a left thyroid nodule measuring 1.4 cm stable compared to prior and possibly reactive right axillary lymph nodes. Bilateral breast MRI noted changes of mastectomy and subpectoral implant reconstruction without evidence of adenopathy and the imaged bones, intrathoracic soft tissues, and intraabdominal soft tissues were unremarkable.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan. Findings:  The physician reviewer found that The records provided for review document that this patient was diagnosed with triple negative breast cancer in 2014 with recurrence in 2018. A PET scan showed activity in a left thyroid nodule measuring 1.4 cm stable compared to prior and possibly reactive right axillary lymph nodes. Bilateral breast MRI noted changes of mastectomy and subpectoral implant reconstruction without evidence of adenopathy and the imaged bones, intrathoracic soft tissues, and intraabdominal soft tissues were unremarkable. Based on the available records, there is no current indication for a PET scan. The National Comprehensive Cancer Network (NCCN) guidelines do not support routine use of PET scans for the surveillance of patients with triple negative breast cancer. Current data have reported that PET imaging has high false-negative rates in the detection of lesions that are smaller than 1 cm or are low grade. For these reasons, the requested PET scan is not medically necessary for 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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: The patient has requested authorization and coverage for bilateral upper lid blepharoplasties.

Answer: dermatochalasis. The patient reports functional deficits related to her decreased vision due to her eyelids.

Answer: In this case, a physical examination and photographs show that the patient has

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral upper lid blepharoplasties. Findings:  The physician reviewer found that Hahn and colleagues note that upper lid blepharoplasty is a common procedure that can be performed safely and reliably. In this case, a physical examination and photographs show that the patient has significant dermatochalasis. The patient reports functional deficits related to her decreased vision due to her eyelids. In this clinical setting, the requested services are medically indicated. Therefore, bilateral upper lid blepharoplasties are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

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


Answer: The patient has requested authorization and coverage for Rinvoq (upadacitinib) extended 24-hour release 15 mg.

Answer: the documentation shows that the patient has tried and failed multiple TNF inhibitors

Answer: In this case, the patient has rheumatoid arthritis and reported good response to Rinvoq.

Context: Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rinvoq (upadacitinib) extended 24-hour release 15 mg. Findings:  The physician reviewer found that In this case, the patient has rheumatoid arthritis and reported good response to Rinvoq. Given that the documentation shows that the patient has tried and failed multiple TNF inhibitors, a trial of another TNF inhibitor when she has had good response to another class of medications is not medically indicated. Therefore, Rinvoq (upadacitinib) extended 24-hour release 15 mg is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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?