Answer: A 59-year-old male enrollee has requested Avastin in combination with gemcitabine and oxaliplatin for the treatment of his hepatocellular carcinoma.

Context: A 59-year-old male enrollee has requested Avastin in combination with gemcitabine and oxaliplatin for the treatment of his hepatocellular carcinoma. Findings:  Two physician reviewers found that there have been a few trials published documenting some degree of efficacy of the combination of oxaliplatin with gemcitabine in hepatocellular carcinoma. There is one phase II study combining these two drugs with Avastin by Zhu and colleagues. This trial demonstrated only that this combination was tolerable in terms of toxicity, but it was inconclusive as to whether the Avastin actually added significant benefit to the combination of oxaliplatin with gemcitabine. While oxaliplatinum with gemcitabine is of clinical benefit in this setting, Avastin remains unproven for this patients condition.

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


Answer: The parent of a 9-year-old male enrollee has requested for a mental health partial hospitalization program for treatment of the enrollees major depressive disorder.

Answer: The record reflects marked impulsivity, and the note indicates this patient recently exhibited aggressive and dangerous behavior toward his sibling.

Context: The parent of a 9-year-old male enrollee has requested for a mental health partial hospitalization program for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that The record reflects marked impulsivity, and the note indicates this patient recently exhibited aggressive and dangerous behavior toward his sibling.  Partial hospitalization allows for close monitoring of medication while adjustments occur, and it also allows for intense interventions for impulsivity and aggression and abnormal involuntary movements by a multi-disciplinary team.

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


Answer: A 55-year-old male enrollee has requested for the use of non-emergent transportation to and from medical appointments for treatment of his condition.

Context: A 55-year-old male enrollee has requested for the use of non-emergent transportation to and from medical appointments for treatment of his condition. Findings:  The physician reviewer found that this need can be met by taking frequent breaks while driving, or he can recline in a private vehicle being transported by someone else. There is no documentation that the patient has any unusual anatomy or skin breakdown such that he cannot be positioned in a private vehicle.

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


Answer: A 63-year-old female enrollee has requested a continuous passive motion (CPM) device for the treatment of her condition.

Context: A 63-year-old female enrollee has requested a continuous passive motion (CPM) device for the treatment of her condition. Findings:  The physician reviewer found that the CPM device is used routinely postoperatively following knee replacement surgery. It has been used extensively for more than twenty years. The equipment is used for one to two weeks postoperatively, and it is sometimes used for knee procedures other than total knee replacement. The CPM device was medically indicated and appropriate for treatment of this patient.

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


Answer: A 30-year-old male enrollee has requested emergency services provided at Scripps Mercy Chula Vista for the treatment of his condition.

Answer: His testicular pain had been present for two months.

Answer: the patient did not require any pain control in the emergency department. He did not present with any other acute symptoms such as abdominal pain.

Context: A 30-year-old male enrollee has requested emergency services provided at Scripps Mercy Chula Vista for the treatment of his condition. Findings:  The physician reviewer found that this patients Health Plan covers emergency services according to the prudent layperson definition. This states that a patient must be suffering from the sudden onset of symptoms of such severity (including severe pain) that a prudent layperson would believe the lack of immediate medical attention would result in serious jeopardy to his health. Although this patient did report pain, the pain was not acute in onset. His testicular pain had been present for two months. Further, the patient did not require any pain control in the emergency department. He did not present with any other acute symptoms such as abdominal pain. While his ongoing testicular pain warranted medical evaluation, this care did not need to be provided on an emergent basis. Because this patient was not experiencing the sudden onset of acute symptoms, his symptoms do not meet criteria for an emergency.

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


Answer: A 65-year-old male enrollee has requested an MRI scan of the knee for an evaluation of his condition.

Context: A 65-year-old male enrollee has requested an MRI scan of the knee for an evaluation of his condition. Findings:  The physician reviewer found that there is a lack of documentation justifying the MRI scan. There is no orthopedic exam is available to review in order to justify the MRI scan.  The MRI report describes some vague findings with respect to the menisci.  Grade II signal commonly is associated with myxoid degeneration of the meniscus, and there is no unequivocal description of pathology within the knee which even retrospectively could be construed as findings requiring operative intervention or even more conservative management such as lack of weight bearing.

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


Answer: The parents of an 18-year-old male enrollee have requested  for inpatient psychiatric center treatment for treatment of the enrollees condition.

Context: The parents of an 18-year-old male enrollee have requested  for inpatient psychiatric center treatment for treatment of the enrollees condition. Findings:  The physician reviewer found that there was no indication that the patient was profoundly depressed, oppositional, suicidal or homicidal. He was not acting out in an overly aggressive or disturbed manner.

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


Answer: A 58-year-old male enrollee has requested Roux-en-Y gastric bypass surgery for the treatment of his excess weight and related conditions.

Answer: This patient has severe morbid obesity with serious comorbid conditions including diabetes and hypertension.

Context: A 58-year-old male enrollee has requested Roux-en-Y gastric bypass surgery for the treatment of his excess weight and related conditions. Findings:  The physician reviewer found that this patient meets nationally accepted criteria for authorization of bariatric surgery. This patient has severe morbid obesity with serious comorbid conditions including diabetes and hypertension. The 2004 Bariatric Surgery Consensus Conference statement supports prompt bariatric surgery in this circumstance.  There is documentation that full reversal of diabetes is severely diminished when surgery is delayed.  Further, surgery will improve the patients life expectancy.  Additionally, and quite significantly, non-operative approaches have nearly 100% failure rate in class III obese patients, such as this patient.

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


Answer: The mother of a 16-year-old female enrollee has requested for Botox injections for treatment of the enrollees migraine headaches.

Context: The mother of a 16-year-old female enrollee has requested for Botox injections for treatment of the enrollees migraine headaches. Findings:  Two physician reviewers found that Botox is a well-accepted and standard of care medication amongst headache specialists for patients failing multiple medications in multiple classes of prophylactic drugs.

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


Answer: A 46-year-old female enrollee has requested an artificial disc replacement procedure at spinal level L4-5 for the treatment of her back pain.

Context: A 46-year-old female enrollee has requested an artificial disc replacement procedure at spinal level L4-5 for the treatment of her back pain. Findings:  Three physician reviewers found that artificial disc replacement is a unique technique for the surgical treatment of discogenic back pain. However, there is a paucity of controlled studies and clinical trials showing the safety and efficacy of this procedure, particularly as compared to interbody fusion surgery.

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


Answer: A 46-year-old female enrollee has requested hormone therapy with testosterone pellet implants for the treatment of her perimenopausal symptoms.

Context: A 46-year-old female enrollee has requested hormone therapy with testosterone pellet implants for the treatment of her perimenopausal symptoms. Findings:  Two physician reviewers found that the use of subcutaneous hormone replacement therapy (HRT) has been reported for many years. Subcutaneous HRT is particularly useful when patients require testosterone supplementation. Subcutaneous testosterone supplementation has been shown to be effective in improving bone density and treating reduced libido and other psychosexual problems. There is no other option currently available (such as transdermal patches) that is as reliable as this method. Transdermal creams and gels cannot be delivered in consistent, accurate doses. Estradiol replacement can be offered simultaneously with subcutaneous testosterone supplementation, providing good benefit and convenience.

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


Answer: A 46-year-old male enrollee has requested for continued physical therapy for treatment of his neck and back pain.

Context: A 46-year-old male enrollee has requested for continued physical therapy for treatment of his neck and back pain. Findings:  The physician reviewer found that the request for continued manual treatment is consistent with a maintenance program and not a restorative program at this point. As such, additional physical therapy sessions are not clinically indicated.

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


Answer: A 44-year-old female enrollee has requested for Avastin for treatment of her recurrent glioblastoma.

Context: A 44-year-old female enrollee has requested for Avastin for treatment of her recurrent glioblastoma. Findings:  Two physician reviewers found that avastin appears active in glioblastoma when combined with chemotherapy and continues to be used in randomized trials to evaluate its efficacy in this population. A phase II trial of Avastin and CPT-11 showed a 63% radiographic response rate with 72% progression-free survival at six months. In this study, all 32 patients had progressed despite radiation therapy and Temodar. In another retrospective study, chemotherapy (carbo/etoposide/or CPT-11) was used with radiation therapy with a report of responses in 7 of 14 patients treated this way.

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


Answer: A 48-year-old male enrollee has requested for Byetta for treatment of his type II diabetes mellitus.

Answer: When the patient began his trial of Byetta, his hemoglobin A1C was 6.2%. His provider indicated the patients A1C varied from 6.1% to 7.3% prior to Byetta

Context: A 48-year-old male enrollee has requested for Byetta for treatment of his type II diabetes mellitus.  Findings:  The physician reviewer found that the best measure of good diabetic control is currently a hemoglobin A1C of less than 6.5%. When the patient began his trial of Byetta, his hemoglobin A1C was 6.2%. His provider indicated the patients A1C varied from 6.1% to 7.3% prior to Byetta; suggesting his glycemic control is dependent on other factors such as diet and exercise. Research has not yet determined the incremental benefit of improving postprandial blood glucose levels when the hemoglobin A1C is already at over below goal.

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


Answer: A 44-year-old male enrollee, with a history of large B-cell lymphoma, has requested authorization for a PET scan.

Context: A 44-year-old male enrollee, with a history of large B-cell lymphoma, has requested authorization for a PET scan.Findings:  Two physician reviewers found that the use of PET scans in the evaluation of large-cell lymphoma is endorsed by National Comprehensive Cancer Network (NCCN) guidelines and by the International Working Group (IWG). PET scans are recommended as baseline evaluations. If they are positive at baseline, they should be performed in follow-up. According to the IWG, PET is essential for post treatment follow-up of diffuse large B-cell lymphoma. PET scans are considered standard of care in this setting.

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


Answer: A 53-year-old female enrollee has requested  Byetta for treatment of her type 2 diabetes mellitus.

Answer: This patients blood glucose is under excellent control. She was

Answer: begun on Byetta to help her lose additional weight

Context: A 53-year-old female enrollee has requested  Byetta for treatment of her type 2 diabetes mellitus. Findings:  The physician reviewer found that Byetta is presently indicated as adjunctive therapy to improve glycemic control in patients with diabetes mellitus type 2 who are taking metformin, sulfonylureas, or thiazolidinediones, alone or in combination, but have not achieved adequate control. This patients blood glucose is under excellent control. She was apparently begun on Byetta to help her lose additional weight which is not the intended purpose of the medication.

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


Answer: A 40-year-old male enrollee has requested the prescription medication Lyrica for treatment of his neck and back pain.

Answer: the patient has been diagnosed with cervical dystonia

Context: A 40-year-old male enrollee has requested the prescription medication Lyrica for treatment of his neck and back pain. Findings:  The physician reviewer found that the patient has been diagnosed with cervical dystonia and is being treated appropriately. Lyrica is not indicated for the pain associated with cervical dystonia. This residual pain is likely to respond to any of a number of interventions including more aggressive Botox therapy, muscle relaxants, Gabapentin or Amitriptyline. The use of Lyrica for this patient would not be considered the standard of care.

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


Answer: A 64-year-old female enrollee has requested the prescription medication Actiq (400mcg lozenge, 90 per 30 days) for treatment of her pain.

Answer: standard measures have not adequately addressed the patients  severe, on-going pain.

Context: A 64-year-old female enrollee has requested the prescription medication Actiq (400mcg lozenge, 90 per 30 days) for treatment of her pain. Findings:  The physician reviewer found that it is clear from the clinical record that standard measures have not adequately addressed the patients  severe, on-going pain. It is also clear that surgical correction of the lumbar radiculopathy or the carpal tunnel syndrome is not feasible because of other complicating medical problems. This is not a situation where high-potency narcotics are being utilized as an off-label substitute for more definitive measures to resolve the pain. Rather, this is a case in which the best available means of pain management has been employed and found to be effective.

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


Answer: A 52-year-old female enrollee has requested reimbursement an Oncotype DX tumor assay for evaluation of her breast cancer.

Context: A 52-year-old female enrollee has requested reimbursement an Oncotype DX tumor assay for evaluation of her breast cancer.  Findings:  Two physician reviewers found that Oncotype DX assay has been found to be reliable in predicting the risk of cancer recurrence within ten years, if the only systemic treatment the woman receives is a hormonal therapy. It has only been validated in node-negative, estrogen receptor positive cancers. It is very difficult to make recommendations about adding adjuvant chemotherapy for this particular group of women. Not only does the Oncotype assay reliably predict the risk of recurrence without chemoterapy, it has also been found to predict the value of chemotherapy. Oncotype DX is widely accepted and has virtually become standard of care for many oncologists. This diagnostic procedure has clearly established clinical value

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


Answer: A 34-year-old female has requested a cold therapy unit for her postoperative rehabilitation.

Context: A 34-year-old female has requested a cold therapy unit for her postoperative rehabilitation. Findings:  The physician reviewer found that postoperative cold therapy is utilized by some orthopedists for managing pain and inflammation. However, use of cold therapy units has not been shown in long-term peer-reviewed literature to offer superiority over the traditional use of ice. The units studied have not been proven to significantly lower the intra-articular temperature of the knee. There is no study literature indicating that use of this device itself would decrease a patients hospital stay or shorten the rehabilitation period.  Appropriate monitoring of the application of ice packs eliminates the concern for skin or tissue break down.

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


Answer: A 49-year-old male enrollee has requested participation in a Phase III clinical trail at the University of Arkansas (UARK 2006-15) for treatment of his multiple myeloma.

Answer: the Phase III trial in question seeks to determine the `standard of care` for patients with multiple myeloma. All of the agents being used are indicated in the treatment of multiple myeloma, as is auto-transplant

Answer: no investigational or experimental agents or regimens are being evaluated. The patient has been determined to be an appropriate candidate for the trial and there do not appear to be any contraindications to his participation in the trial. The proposed clinical trial is evaluating the use of Velcade in the setting of debulking chemotherapy and tandem transplants. The use of high-dose chemotherapy and tandem transplantation is considered standard of care. Velcade is an FDA approved drug for the treatment of multiple myeloma.

Context: A 49-year-old male enrollee has requested participation in a Phase III clinical trail at the University of Arkansas (UARK 2006-15) for treatment of his multiple myeloma. Findings:  Two physician reviewers found that the Phase III trial in question seeks to determine the `standard of care` for patients with multiple myeloma. All of the agents being used are indicated in the treatment of multiple myeloma, as is auto-transplant, which can be performed with curative intent for myeloma. Thus, no investigational or experimental agents or regimens are being evaluated. The patient has been determined to be an appropriate candidate for the trial and there do not appear to be any contraindications to his participation in the trial. The proposed clinical trial is evaluating the use of Velcade in the setting of debulking chemotherapy and tandem transplants. The use of high-dose chemotherapy and tandem transplantation is considered standard of care. Velcade is an FDA approved drug for the treatment of multiple myeloma. Given this patients age and prognosis, the proposed clinical trial is likely to be his best opportunity for disease control/eradication under these clinical circumstances. The proposed post-transplant randomization does not compromise the standard of care, and appears to be testing the role of a drug known to be active in this clinical setting.

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


Answer: The parents of a seventeen month-old male with respiratory distress requiring intubation, surfactant, and episodes of supraventricular tachycardia (SVT) are requesting reimbursement and prospective authorization for Synagis (palivizumab).

Context: The parents of a seventeen month-old male with respiratory distress requiring intubation, surfactant, and episodes of supraventricular tachycardia (SVT) are requesting reimbursement and prospective authorization for Synagis (palivizumab).  Reviewers Findings:  The reviewing physician found that RSV infection has been associated with tachyarrhythmias including SVT that may be hemodynamically significant in infants such as this one.  The reviewing physician found that the Health Plan denial should be overturned.

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


Answer: The parent of a four-year-old female enrollee has requested magnetoencephalography (MEG) and magnetic source imaging for evaluation of the enrollees epilepsy.

Context: The parent of a four-year-old female enrollee has requested magnetoencephalography (MEG) and magnetic source imaging for evaluation of the enrollees epilepsy. Findings:  Two physician reviewers found that a review of the recent peer-reviewed literature indicates that MEG and magnetic source imaging can play an important role in epilepsy mapping. While the procedures are not widely used, their use in select patients with intractable seizure activity has allowed physicians to determine if a patient is appropriate for epilepsy surgery and to provide detailed mapping for pre-surgical planning. In the past, the gold standard for epilepsy mapping was the use of intracranial electrodes. There is risk associated with any surgical procedure and  particularly with brain surgery. MEG is a safer, non-invasive means of obtaining the same information as would be obtained from intracranial EEG (ICEEG).

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


Answer: A forty-three year-old female with severe urticaria is requesting authorization of Xolair.

Context: A forty-three year-old female with severe urticaria is requesting authorization of Xolair.Reviewers Findings:  The reviewing physician found that the FDA approved indication for Xolair is moderate to severe persistent asthma in patients who have: a positive skin test or in vitro reactivity to a perennial aeroallergen, symptoms inadequately controlled with inhaled corticosteroids, and pre-treatment total IgE levels of 30 or greater. The submitted records document the patient does meet the criteria. The reviewing physician found that the Health Plan denial should be upheld.

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


Answer: The parents of a five-year-old male diagnosed with ataxic cerebral palsy are requesting authorization for an MR spectroscopy.

Context: The parents of a five-year-old male diagnosed with ataxic cerebral palsy are requesting authorization for an MR spectroscopy.  Reviewers Findings:  The reviewing physician found that the relevant literature concerning MR spectroscopy shows there is insufficient proof of its value in this clinical setting at this time.  The reviewing physician found that the Health Plan denial should be upheld.

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


Answer: A twenty-five year-old female with a history of bulimia nervosa is requesting reimbursement for residential treatment services.

Context: A twenty-five year-old female with a history of bulimia nervosa is requesting reimbursement for residential treatment services.Reviewers Findings:The reviewing physician found that the patient appears to have been greatly compromised by her eating disorder.  The reviewing physician found that the Health Plan denial should be overturned.

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


Answer: A 45-year-old male enrollee has requested Gleevec for treatment of his desmoid tumor.

Context: A 45-year-old male enrollee has requested Gleevec for treatment of his desmoid tumor.  Findings:  Three physician reviewers found that Desmoid tumor (aggressive fibromatosis) can be a recurrent, though not metastatic, form of neoplasia. Standard chemotherapy has rarely been of much value. Gleevec, which is approved for use in chronic myelogenous leukemia and gastrointestinal stromal tumors, has indeed been reported to have some efficacy in desmoid tumors. There are multiple papers documenting this as cited above. Because of the rarity of desmoid tumor, Gleevec will probably never be approved for treatment of this condition. However, there is enough data to believe it is more likely to be effective than any of the more conventional forms of chemotherapy than might be offered.

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


Answer: A forty-two year-old female with a history of nausea and vomiting is requesting reimbursement for the antroduodenal motility/manometry studies and the electrogastrogram.

Context: A forty-two year-old female with a history of nausea and vomiting is requesting reimbursement for the antroduodenal motility/manometry studies and the electrogastrogram.Reviewers FindingsAfter reviewing the requests, two of the three physicians found the electrogastrogram was not likely to be more beneficial for evaluation. Two of the three physicians found that antroduodenal motility/manometry studies were likely to be more beneficial for evaluation.  The reviewing physicians found the Health Plan denial should be partially overturned.

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


Answer: The patient is a 45-year-old woman with an ankle fracture. During the course of her treatment a bone stimulator was utilized. The patient had proper immobilization of her fracture. It was noted at eight to ten weeks that she had no callus and persistent tenderness. Ultimately, it was felt she had a delayed union and surgical intervention was recommended. The patient is seeking reimbursement for the use of the bone growth stimulator. The Health Plan has denied her request citing a lack of medical necessity for the device.

Context: The patient is a 45-year-old woman with an ankle fracture. During the course of her treatment a bone stimulator was utilized. The patient had proper immobilization of her fracture. It was noted at eight to ten weeks that she had no callus and persistent tenderness. Ultimately, it was felt she had a delayed union and surgical intervention was recommended. The patient is seeking reimbursement for the use of the bone growth stimulator. The Health Plan has denied her request citing a lack of medical necessity for the device.The use of a bone growth stimulator in this case was medically reasonable and acceptable. If the bone growth stimulator was effective, the patients pain would have diminished and her condition would have improved without the need for invasive treatment (i.e., surgery). Unfortunately, in this case union was not achieved and surgery was required. However, since the bone growth stimulator provided the potential of preventing the patient from having surgery, its use was clinically appropriate. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.

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


Answer: The patient is a 49-year-old female who underwent arthroscopic surgery on her right knee in March 2006. A cold therapy unit was utilized post-operatively. The patients request for reimbursement for the cold therapy unit has been denied by the Health Plan on the basis that it was not medically necessary.

Context: The patient is a 49-year-old female who underwent arthroscopic surgery on her right knee in March 2006. A cold therapy unit was utilized post-operatively. The patients request for reimbursement for the cold therapy unit has been denied by the Health Plan on the basis that it was not medically necessary.Cold therapy units are extremely useful post-operatively to diminish pain and swelling. Use of cold therapy is an established modality and is generally accepted as beneficial in this clinical setting. It is superior to ice packs and patients achieve significant relief with its use. In the case of this patient, she clearly experienced a benefit from use of the cold therapy unit following her surgery. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

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


Answer: The patient is a 53-year-old woman who reports a six-year history of gastrointestinal problems. She states that she became ill in December 2000 after eating watercress and drinking water from a stream. She reports multiple problems including irritable bowel syndrome, constipation, gas and abdominal bloating. The patient also experiences extreme fatigue, concentration problems, and short-term memory loss. She wishes to undergo further workup with an Intestinal Permeability and Comprehensive Digestive Stool Analysis. The Health Plan indicates the proposed testing is not medically necessary for evaluation of the patients condition.

Answer: she has undergone a thorough workup with evaluations by multiple specialists.

Context: The patient is a 53-year-old woman who reports a six-year history of gastrointestinal problems. She states that she became ill in December 2000 after eating watercress and drinking water from a stream. She reports multiple problems including irritable bowel syndrome, constipation, gas and abdominal bloating. The patient also experiences extreme fatigue, concentration problems, and short-term memory loss. She wishes to undergo further workup with an Intestinal Permeability and Comprehensive Digestive Stool Analysis. The Health Plan indicates the proposed testing is not medically necessary for evaluation of the patients condition.The Health Plans denial is correct. The patient has vague and generalized symptoms. It appears she has undergone a thorough workup with evaluations by multiple specialists. The use of the proposed intestinal permeability test in this patient is not within the community standard of care. The requested testing is not likely to add clinically useful information for the care and management of this patient. Therefore, I have determined the requested testing is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.

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


Answer: The patient is a 36-year-old female who underwent Lap-band surgery in June 2004, and reports that after months of attempts to control her subsequent nausea and vomiting she elected to have the band removed. She then underwent a gastric bypass operation in July 2005. She reports only a 10-pound weight loss following that procedure. The patient at this time is reported to be 56 weighing 241 pounds with a body mass index (BMI) of 39. Her comorbid conditions include gastroesophageal reflux disease (GERD), asthma, exertional dyspnea, depression and anxiety. The patients provider has proposed gastric bypass revision to reduce the size of the patients stomach pouch and outlet.

Answer: The patient reports GERD as a comorbid condition.

Context: The patient is a 36-year-old female who underwent Lap-band surgery in June 2004, and reports that after months of attempts to control her subsequent nausea and vomiting she elected to have the band removed. She then underwent a gastric bypass operation in July 2005. She reports only a 10-pound weight loss following that procedure. The patient at this time is reported to be 56 weighing 241 pounds with a body mass index (BMI) of 39. Her comorbid conditions include gastroesophageal reflux disease (GERD), asthma, exertional dyspnea, depression and anxiety. The patients provider has proposed gastric bypass revision to reduce the size of the patients stomach pouch and outlet. Review of the clinical evidence indicates the patients two previous weight loss surgical procedures were unsuccessful. The patients first procedure, the Lap-band, has a significant published rate of solid intolerance, nausea and vomiting associated with the procedure. After the gastric band was removed the patient underwent gastric bypass, also without success. The scientific data shows duodenal switch has the best long-term success of all weight loss surgical procedures. There is one peer-reviewed, published article that reports the outcome of patients with multiple weight loss surgical procedures. This article not only demonstrates the superior long-term outcome of the duodenal switch as a revisional operation, but also shows that patients with multiple previous restrictive operations (Lap-band, gastric bypass, etc.) will fail any other revision unless they have an operation that limits absorption as well.  The patient reports GERD as a comorbid condition. If her gastrojejunostomy anastomosis is reduced from 2.5 cm to 1.5 cm as proposed by her surgeon, it is likely the patients reflux disease will significantly worsen. Thus, although the patient meets criteria for a revisional weight loss procedure, the proposed procedure is not likely to result in adequate weight loss and will probably worsen her reflux disease. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.

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


Answer: The patient is a 48-year-old female with a BMI of 43. She has a number of comorbid conditions including asthma, diabetes mellitus type 2, and depression. She has requested authorization for gastric bypass surgery.

Context: The patient is a 48-year-old female with a BMI of 43. She has a number of comorbid conditions including asthma, diabetes mellitus type 2, and depression. She has requested authorization for gastric bypass surgery. There is no evidence that the patient has undergone a psychological evaluation to determine whether she is considered an appropriate candidate for weight loss surgery.With a BMI of 43 and comorbid conditions such as diabetes the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. However, although medically the patient meets criteria for consideration of weight loss surgery, the patient has not yet obtained psychological clearance for weight loss surgery. Based upon the information set forth above, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the requested procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery, the requested procedure should not be authorized.

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


Answer: The patient is a 33-year-old male who is undergoing evaluation for sleep apnea.  He has complaints of loud snoring, disrupted breathing while sleeping, feeling unrested upon awakening, memory difficulties and sexual dysfunction.  Comorbid conditions include hypertension, obesity and depression.  The patients request for inpatient polysomnography has been denied by the Health Plan as not medically necessary.

Context: The patient is a 33-year-old male who is undergoing evaluation for sleep apnea.  He has complaints of loud snoring, disrupted breathing while sleeping, feeling unrested upon awakening, memory difficulties and sexual dysfunction.  Comorbid conditions include hypertension, obesity and depression.  The patients request for inpatient polysomnography has been denied by the Health Plan as not medically necessary.The patient does meet the clinical criteria for evaluation of a possible sleep disorder by polysomnography. However, an overnight stay in a hospital is not necessary if the option of an adequate home sleep study is available for diagnosis.  The home sleep study should include the monitoring of at least four parameters, not simply pulse oximetry or airflow.  If the patient needs support to ensure that the study is performed correctly, an attendant should be provided to assist with the setup of the equipment and possible monitoring.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.

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


Answer: The patient is a 19-year-old male with idiopathic short stature and constitutionally delayed puberty. He was born the smaller of two twins weighing 2 pounds with his sibling weighing 5 pounds 4 ounces. The mid-parental height approximates 68 inches. On October 2005 the patients bone age was 15.5 years, while his height was near 53. His adult height prediction on these bases should approximate 54. He has had an endocrine workup, which revealed normal GH responses to stimuli, normal adult male hormone levels and a normal IGF-1 level of 184 in October 2004.

Answer: the patient has been on growth hormone therapy since January 2006. At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.

Context: The patient is a 19-year-old male with idiopathic short stature and constitutionally delayed puberty. He was born the smaller of two twins weighing 2 pounds with his sibling weighing 5 pounds 4 ounces. The mid-parental height approximates 68 inches. On October 2005 the patients bone age was 15.5 years, while his height was near 53. His adult height prediction on these bases should approximate 54. He has had an endocrine workup, which revealed normal GH responses to stimuli, normal adult male hormone levels and a normal IGF-1 level of 184 in October 2004. Based upon the information provided, it appears the patient has been on growth hormone therapy since January 2006. At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.Review of the submitted clinical evidence demonstrates the patient meets medical necessity criteria for growth hormone therapy. In accordance with the AACE Medical Guidelines for growth hormone therapy, the therapy is medically necessary for patients such as this patient who was a small for gestational age infant who has not caught up, and is falling further from normal percentiles, and/or has idiopathic short stature and is not projected to achieve an adult height in the normal range and is under the care of a pediatric endocrinologist. The problem is however that the patients remaining growing time is very short and it is not known to what extent such therapy will be beneficial. Therefore, growth intervals should be obtained on a regular basis (every three months) to document that the patient is continuing to grow. In addition, a knee x-ray would be helpful to show the state of the epiphyses in the knee. Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.

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


Answer: The patient is a 47-year-old male with chronic back pain and is status post multiple lumbar surgeries. In addition, the patient underwent gastric bypass surgery in 2004. He is requesting authorization for 630 80mg OxyContin tablets per month for pain control. The Health Plan has authorized 540 80mg tablets of OxyContin per month. At issue is whether the requested prescription is medically necessary for treatment of the patients chronic pain.

Context: The patient is a 47-year-old male with chronic back pain and is status post multiple lumbar surgeries. In addition, the patient underwent gastric bypass surgery in 2004. He is requesting authorization for 630 80mg OxyContin tablets per month for pain control. The Health Plan has authorized 540 80mg tablets of OxyContin per month. At issue is whether the requested prescription is medically necessary for treatment of the patients chronic pain.The Health Plans denial should be upheld. The amount of OxyContin the patient is requesting is well beyond the standard of care in pain management medicine, even in extreme cases. The requested prescription is excessive and not medically appropriate. The patient should pursue alternative forms of pain management in addition to narcotic management in order to allow for a decrease in his current level of OxyContin. Accordingly, I have determined the requested prescription is not medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be upheld.

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


Answer: The patient is a 31-year old female who has failed traditional medical care in eliminating or managing her head pain.  The patient reports she has obtained positive results from chiropractic care.

Answer: The patient has requested that chiropractic care be authorized on an unlimited basis.  The Health Plan has denied authorization for continued chiropractic care on the basis it is not medically necessary.

Answer: In this case, the patient states she finds chiropractic helpful in providing relief and in improving her quality of life.  By her assessment, the headaches have lessened and become controlled unlike before and she requires less medication.

Answer: after the second chiropractic reassessment, she was on a supportive treating schedule.

Context: The patient is a 31-year old female who has failed traditional medical care in eliminating or managing her head pain.  The patient reports she has obtained positive results from chiropractic care. The submitted records do not include detailed outcome assessments made by her provider.  The patient has requested that chiropractic care be authorized on an unlimited basis.  The Health Plan has denied authorization for continued chiropractic care on the basis it is not medically necessary.   A diagnosis of cervicogenic headache is one that is often treated successfully with chiropractic care.  Head pain can be a quality of life issue for the patient and it can be difficult for a clinician to achieve and maintain the desired results. Often, co-management is a better approach.  In this case, the patient states she finds chiropractic helpful in providing relief and in improving her quality of life.  By her assessment, the headaches have lessened and become controlled unlike before and she requires less medication.  This patients condition however, is chronic and after the second chiropractic reassessment, she was on a supportive treating schedule. There is no documentation of objective outcome measures being consistently monitored to determine the patients progress. In the absence of such documentation, medical necessity for continued chiropractic care has not been established.The Health Plans alternative recommendation for orthopedic consultation, pain management evaluation and assessment of work and lifestyle for contributing factors is reasonable and those services should be made available to the patient.  Should that approach fail, the patients request for additional chiropractic care should be reconsidered.Based upon the information set forth above, I have determined the requested chiropractic care is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.

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


Answer: The patient is a 50-year-old woman who presented with an explosive course of bronchoalveolar adenocarcinoma and respiratory failure. She had a dramatic response to treatment with Iressa. When she later reached a plateau on Iressa, she was switched to Tarceva.  The Health Plan indicates it will not authorize Tarceva because it is not considered medically necessary unless it follows failed treatment with a platinum-based chemotherapy.When this patient initially presented, she was too sick for chemotherapy.  She was treated with Iressa, an EGFR-targeted treatment, and had a remarkable response.

Context: The patient is a 50-year-old woman who presented with an explosive course of bronchoalveolar adenocarcinoma and respiratory failure. She had a dramatic response to treatment with Iressa. When she later reached a plateau on Iressa, she was switched to Tarceva.  The Health Plan indicates it will not authorize Tarceva because it is not considered medically necessary unless it follows failed treatment with a platinum-based chemotherapy.When this patient initially presented, she was too sick for chemotherapy.  She was treated with Iressa, an EGFR-targeted treatment, and had a remarkable response. Although Tarcevas current indication is for second line treatment, it is another EGFR-targeted treatment that is routinely being used for subsets of patients with a high likelihood of benefit.  This patients response to Iressa indicates the expected benefit of Tarceva is far greater than that of a platinum-based chemotherapy.  The Health Plans guidelines would require a failed trial of platinum-based chemotherapy before the patient could continue with Tarceva, the treatment most likely to produce a positive result. Uninterrupted treatment with Tarceva is a more prudent course of treatment for this patient.  Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.

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


Answer: The patient is a 40-year-old female with a history of migraines, worse with menstruation, for at least six years. In January 2005, the patients physician recommended an MRI of the brain due to an increase in the frequency of headaches. The MRI was unremarkable. The submitted status reports indicate that while the patient may have had a favorable response to various medications, it was only for a short duration. The patient started receiving acupuncture in February 2005. In addition, she changed her eating habits and began exercising regularly. The patient reports this regimen has helped reduce the frequency of her migraines and that she has lost weight and is generally feeling better with acupuncture treatment. The patient further indicates she has been able to reduce her medication dosage.  At issue is whether acupuncture is medically necessary for treatment of the patients medical condition.

Context: The patient is a 40-year-old female with a history of migraines, worse with menstruation, for at least six years. In January 2005, the patients physician recommended an MRI of the brain due to an increase in the frequency of headaches. The MRI was unremarkable. The submitted status reports indicate that while the patient may have had a favorable response to various medications, it was only for a short duration. The patient started receiving acupuncture in February 2005. In addition, she changed her eating habits and began exercising regularly. The patient reports this regimen has helped reduce the frequency of her migraines and that she has lost weight and is generally feeling better with acupuncture treatment. The patient further indicates she has been able to reduce her medication dosage.  At issue is whether acupuncture is medically necessary for treatment of the patients medical condition.Because of the patients poor response to prescribed medications and her more favorable response to acupuncture treatment, continued acupuncture is more appropriate for treatment of the patients medical condition than pharmacotherapy. Since the patients symptoms appear to worsen during her menstrual period, one or two acupuncture treatments at that time are indicated for relief of migraines associated with her period. In addition, the patient should continue her exercise program and improved eating habits. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.

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


Answer: The patient is a 45-year-old man who underwent ACL reconstruction. Postoperatively the patient utilized a continuous passive motion (CPM) machine. The Health Plan has denied reimbursement for utilization of the CPM machine on the basis it was not medically necessary for treatment of the patients condition.

Context: The patient is a 45-year-old man who underwent ACL reconstruction. Postoperatively the patient utilized a continuous passive motion (CPM) machine. The Health Plan has denied reimbursement for utilization of the CPM machine on the basis it was not medically necessary for treatment of the patients condition.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. Numerous studies have shown benefit with CPM. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the device was felt to be of benefit following the patients ACL reconstruction. Furthermore, there are no significant risks posed by use of a CPM machine. A CPM machine was medically reasonable and indicated for the patients successful postoperative rehabilitation. Therefore, I have determined that the equipment at issue was medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.

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


Answer: The patient is a 58-year-old female who felt a small nodule in the inferior medial left breast. Mammogram in August 2004 was negative. In August 2004, the patient was evaluated by her clinician who performed an ultrasound and a core biopsy of a 1 cm mass at 7oclock. The pathology was fibroadipose tissue. In September 2004, the patient then underwent an excisional biopsy. The pathology results were benign nonproliferative fibrocystic changes. There was no evidence of malignancy.In a follow-up appointment with her clinician in November 2004, three fatty nodules were palpated at 9 oclock in the left breast. An MRI was ordered for further evaluation, which was performed in mid-November 2004. The patient has no history of breast cancer and has been on estrogen for many years. The Health Plan has denied reimbursement for the MRI at issue on the basis it was not medically necessary for evaluation of the patients medical condition.

Context: The patient is a 58-year-old female who felt a small nodule in the inferior medial left breast. Mammogram in August 2004 was negative. In August 2004, the patient was evaluated by her clinician who performed an ultrasound and a core biopsy of a 1 cm mass at 7oclock. The pathology was fibroadipose tissue. In September 2004, the patient then underwent an excisional biopsy. The pathology results were benign nonproliferative fibrocystic changes. There was no evidence of malignancy.In a follow-up appointment with her clinician in November 2004, three fatty nodules were palpated at 9 oclock in the left breast. An MRI was ordered for further evaluation, which was performed in mid-November 2004. The patient has no history of breast cancer and has been on estrogen for many years. The Health Plan has denied reimbursement for the MRI at issue on the basis it was not medically necessary for evaluation of the patients medical condition.There are several indications for MRI of the breast, which include pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high-risk patients, and problem solving. An indication for non-malignant disease is evaluation of breast implants.Since this patient had a relatively recent mammogram, ultrasound, ultrasound-guided biopsy, and excisional biopsy of the left breast, a new malignancy in the breast would be very unlikely. A repeat left breast mammogram and ultrasound and follow-up clinical exam would have been appropriate before considering MRI and possibly another biopsy. Given the specifics of this case, an MRI was not medically warranted for this patient.Based upon the information set forth above, I have determined that the MRI at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.

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


Answer: The patient is a 58-year-old female with a history of back, neck, and shoulder pain. She was seen by a chiropractor who suggested the patients symptoms would probably benefit from breast reduction surgery. The patient was previously seen by a physical therapist and a neurosurgeon for other back pain in the past. It appears from the submitted documentation that the board certified plastic surgeon who requested authorization for breast reduction surgery agreed the patient would benefit from the requested procedure. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is not medically necessary.

Context: The patient is a 58-year-old female with a history of back, neck, and shoulder pain. She was seen by a chiropractor who suggested the patients symptoms would probably benefit from breast reduction surgery. The patient was previously seen by a physical therapist and a neurosurgeon for other back pain in the past. It appears from the submitted documentation that the board certified plastic surgeon who requested authorization for breast reduction surgery agreed the patient would benefit from the requested procedure. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is not medically necessary.The submitted photocopies of photographs are of poor quality. Therefore, it is not possible to confirm that the patients breast size results in medical complications. Furthermore, the submitted consultation notes are insufficient to support medical necessity for breast reduction surgery. As such, it has not been established the requested procedure is medically warranted at this time. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.

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


Answer: The patient is a 43-year-old female who has a history of depression and alcohol abuse. She began inpatient hospitalization in 2005. At the time of her admission, the patient was suicidal as evidenced by an emergency room visit secondary to taking excessive Xanax and alcohol. In the psychiatric history and evaluation, the patients chief complaint was constant thoughts of not wanting to be around. A request has been made for coverage for continued inpatient psychiatric treatment services. The Health Plan indicates the submitted documentation does not demonstrate the requested services are medically necessary.

Context: The patient is a 43-year-old female who has a history of depression and alcohol abuse. She began inpatient hospitalization in 2005. At the time of her admission, the patient was suicidal as evidenced by an emergency room visit secondary to taking excessive Xanax and alcohol. In the psychiatric history and evaluation, the patients chief complaint was constant thoughts of not wanting to be around. A request has been made for coverage for continued inpatient psychiatric treatment services. The Health Plan indicates the submitted documentation does not demonstrate the requested services are medically necessary.Although the patient had symptoms consistent with active suicidality upon admission, these symptoms were most likely precipitated or exacerbated by active alcohol intoxication. There is scant evidence in the medical record to suggest ongoing suicidality. It would have been medically reasonable and appropriate to transfer the patient to partial hospitalization or outpatient chemical dependency program, at which point the patient was stable. There is no evidence of acute alcohol withdrawal symptoms at the time of admission. Detoxification was optimal and certainly could have been completed. Therefore, I have determined that inpatient psychiatric treatment services were medically necessary. The Health Plans denial should be partially overturned.

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


Answer: The patient is a five-year-old male with a history of migraines, headaches, asthma, and allergies. Acupuncture has been recommended for treatment of these conditions. The Health Plan has denied this request on the basis acupuncture is not medically necessary for treatment of the patients condition.

Context: The patient is a five-year-old male with a history of migraines, headaches, asthma, and allergies. Acupuncture has been recommended for treatment of these conditions. The Health Plan has denied this request on the basis acupuncture is not medically necessary for treatment of the patients condition.According to the California Department of Consumer Affairs, Acupuncture Board, the National Institutes of Health, and the World Health Organization, acupuncture is an acceptable and appropriate treatment for this patients condition. Acupuncture is commonly utilized to treat allergies/asthma, migraine headache, rhinitis, and sinusitis. There are controlled trials demonstrating acupuncture is an effective treatment for allergic rhinitis. Standard treatment for this patient would be acupuncture twice weekly for three to four weeks followed by evaluation to determine if further treatment is indicated.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.

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


Answer: The patient is a 41-year-old male with erectile dysfunction. He had a complete physical examination and no specific etiology was identified. Treatment with Viagra was not successful but subsequent treatment with Levitra was successful. The Health Plan has denied authorization for Levitra because there is no known organic cause for the enrollees dysfunction.

Context: The patient is a 41-year-old male with erectile dysfunction. He had a complete physical examination and no specific etiology was identified. Treatment with Viagra was not successful but subsequent treatment with Levitra was successful. The Health Plan has denied authorization for Levitra because there is no known organic cause for the enrollees dysfunction. The cause of erectile dysfunction is irrelevant to the treatment. Regardless of the cause of erectile dysfunction, medications such as Viagra and Levitra are considered first-line therapy. This patient has experienced benefit from Levitra after having failed Viagra. Based upon these results, treatment of the patients erectile dysfunction with Levitra is medically necessary. Therefore, the Health Plans denial should be overturned.

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


Answer: The patient is a 53-year-old female with a history of a cyst on her right eye. The cyst has apparently recently grown in size. The patients provider has recommended excision of the cyst. The Health Plan has denied this request.

Answer: The drawing in the ophthalmologists record shows a moderate pinguecula

Context: The patient is a 53-year-old female with a history of a cyst on her right eye. The cyst has apparently recently grown in size. The patients provider has recommended excision of the cyst. The Health Plan has denied this request.The clinical evidence does not demonstrate the medical necessity of the requested medication. The submitted photographs do not provide clear or objective evidence of the patients condition. The drawing in the ophthalmologists record shows a moderate pinguecula with only a tiny extension onto the cornea. These are common, benign and virtually never require surgery. If they enlarge and extend onto the cornea, they are classified as pterygium. A decision to proceed with surgery would then be based on the extent to which the pterygium extended into the visual axis. There is no evidence of this in this case. Furthermore, inflamed pinguecula usually respond to topical therapy. There is no evidence this patient has attempted a trial of topical therapy. Moreover, a biopsy would be indicated prior to consideration of surgery after failure of topical therapy. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.

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


Answer: The patient is a 42-year-old female with previously diagnosed depression, morbid obesity, and binge eating disorder

Answer: The patient was admitted to partial hospitalization on 2/16/04 where she was treated with a number of psychotherapies as well as Lexapro. Pertinent social stressors have included her mothers alcohol dependence, an emotionally abusive husbands past infidelity, and her teenage sons involvement with drugs and alcohol and poor performance in school. Her tendency has been to overeat when distressed. During her stay in the partial hospitalization program, the patients weight decreased from 334 pounds to 319 pounds by 5/12/04. The chart notes point to the patients growing insight about her aforementioned stressors and her emotional reaction by way of overeating. The therapists notes of 5/5/04 indicate, her family is emotionally reacting to her positive changes. In discussing this the patient made many realizations and showed great insight. The patient has requested authorization and coverage for continued partial hospitalization services. The Health Plan has denied the request indicating that the submitted documentation does not demonstrate partial hospitalization services were medically necessary as of 5/12/04.

Answer: the patient improved during partial hospitalization, experiencing a weight loss of approximately 15 pounds, and a growing awareness of the triggers for overeating.

Context: The patient is a 42-year-old female with previously diagnosed depression, morbid obesity, and binge eating disorder, though not bulimia per se. The patient was admitted to partial hospitalization on 2/16/04 where she was treated with a number of psychotherapies as well as Lexapro. Pertinent social stressors have included her mothers alcohol dependence, an emotionally abusive husbands past infidelity, and her teenage sons involvement with drugs and alcohol and poor performance in school. Her tendency has been to overeat when distressed. During her stay in the partial hospitalization program, the patients weight decreased from 334 pounds to 319 pounds by 5/12/04. The chart notes point to the patients growing insight about her aforementioned stressors and her emotional reaction by way of overeating. The therapists notes of 5/5/04 indicate, her family is emotionally reacting to her positive changes. In discussing this the patient made many realizations and showed great insight. The patient has requested authorization and coverage for continued partial hospitalization services. The Health Plan has denied the request indicating that the submitted documentation does not demonstrate partial hospitalization services were medically necessary as of 5/12/04.Analysis and Findings:While the patient entered partial hospitalization to better contain her overeating and anxiety, she had a rather protracted course of such treatment for a multitude of problems that are often treated with no more intensive therapy than outpatient care. In any event, the submitted records indicate the patient improved during partial hospitalization, experiencing a weight loss of approximately 15 pounds, and a growing awareness of the triggers for overeating. There is nothing in the submitted records to indicate the patient warranted partial hospitalization beyond 5/12/04. There is no evidence that as of 5/12/04 the patient was experiencing any particularly acute problems. Outpatient treatment services as recommended by the Health Plan are medically reasonable and appropriate for the ongoing care of this patient. Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.

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


Answer: The patient is a 43-year-old female who presents with neck and back pain as well as right side upper extremity pain. No cause or incident for the pain is evident. Chiropractic care has been provided 18 times over several months. The patient indicates she is in constant pain and is unable to work despite a recent course of chiropractic care. The patient notes on the chiropractic intake forms that her complaints are all the time, extreme, and she has neck pain on swallowing. An x-ray exam has been requested by the chiropractor

Answer: The patient has requested authorization for continued chiropractic care. The Health Plan has denied the patients request on the basis that continued chiropractic care is not medically necessary for treatment of the patients medical condition.

Context: The patient is a 43-year-old female who presents with neck and back pain as well as right side upper extremity pain. No cause or incident for the pain is evident. Chiropractic care has been provided 18 times over several months. The patient indicates she is in constant pain and is unable to work despite a recent course of chiropractic care. The patient notes on the chiropractic intake forms that her complaints are all the time, extreme, and she has neck pain on swallowing. An x-ray exam has been requested by the chiropractor but the submitted documentation does not indicate if the exam was performed. The patient has requested authorization for continued chiropractic care. The Health Plan has denied the patients request on the basis that continued chiropractic care is not medically necessary for treatment of the patients medical condition.Upon review of the patients records it appears she has made little progress with chiropractic care. Additionally, the submitted records do not demonstrate that other causes for the patients arm complaints have been ruled out or that referrals have been made. Chiropractic care has been given an adequate opportunity to cure or relieve the patients pain. Continued chiropractic care is not likely to be clinically beneficial to this patients current complaints. The patient should receive a referral to her primary care physician for further workup or a referral to rule out other causation or to suggest possible curative care approaches. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.

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


Answer: The patient is a five-year-old male who has been diagnosed as having ADHD, hyperactive type. Pervasive developmental disorder - not otherwise specified, and mental retardation have been ruled out. The patient was initially treated with Adderall immediate release with positive response. The medication was later switched to Adderall XR (long-acting), which was given only once per day. The patient continues to have positive response to Adderall therapy. The patient has not been tried on any other psychostimulant. A request has been made for authorization of Adderall XR. The Health Plan has denied the request on the basis that Adderall XR is not medically necessary.

Answer: the patient has had a positive response to Adderall XR

Answer: the patient had significant positive response to immediate release Adderall.

Context: The patient is a five-year-old male who has been diagnosed as having ADHD, hyperactive type. Pervasive developmental disorder - not otherwise specified, and mental retardation have been ruled out. The patient was initially treated with Adderall immediate release with positive response. The medication was later switched to Adderall XR (long-acting), which was given only once per day. The patient continues to have positive response to Adderall therapy. The patient has not been tried on any other psychostimulant. A request has been made for authorization of Adderall XR. The Health Plan has denied the request on the basis that Adderall XR is not medically necessary. Though the submitted records indicate the patient has had a positive response to Adderall XR it has not been established that Adderall XR is medically necessary for treatment of the patients ADHD. The records demonstrate the patient had significant positive response to immediate release Adderall. There is no documentation of significant rebound on the immediate release version of Adderall. Furthermore, Adderall XR has not been approved for use in children under the age of six. Moreover, the submitted documentation does not demonstrate the patient has experienced complications that would warrant use of the long-acting version of Adderall. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.

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


Answer: A 28-year-old female enrollee requested authorization and coverage of biofeedback therapy. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees rectal incontinence.

Context: A 28-year-old female enrollee requested authorization and coverage of biofeedback therapy. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees rectal incontinence. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.

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


Answer: A 57-year-old female enrollee requested authorization and coverage of a repeat Dexa scan. The Health Plan denied the request indicating that the requested Dexa scan is not medically necessary for evaluation of the enrollees osteoporosis.

Context: A 57-year-old female enrollee requested authorization and coverage of a repeat Dexa scan. The Health Plan denied the request indicating that the requested Dexa scan is not medically necessary for evaluation of the enrollees osteoporosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested Dexa scan is not medically necessary.

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


Answer: A 57-year-old female enrollee requested authorization and coverage of an MRI of the left breast. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of a lump in the enrollees breast.

Context: A 57-year-old female enrollee requested authorization and coverage of an MRI of the left breast. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of a lump in the enrollees breast.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested MRI is medically necessary.

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


Answer: A 38-year-old female enrollee requested authorization and coverage of gastric banding. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees morbid obesity.

Context: A 38-year-old female enrollee requested authorization and coverage of gastric banding. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.

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


Answer: A 43-year-old female enrollee requested authorization and coverage of a gastric bypass surgery consultation. The Health Plan denied this request indicating that the requested consultation is not medically necessary for evaluation of the enrollees morbid obesity.

Context: A 43-year-old female enrollee requested authorization and coverage of a gastric bypass surgery consultation. The Health Plan denied this request indicating that the requested consultation is not medically necessary for evaluation of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested consultation is medically necessary.

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


Answer: A female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees hyperhidrosis.

Context: A female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees hyperhidrosis.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.

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


Answer: A 30-year-old male enrollee requested authorization and coverage of a bilateral mastectomy with ultrasound and suction-assisted lipectomy. The Health Plan denied the request indicating that the procedure is cosmetic in nature and not medically necessary.

Context: A 30-year-old male enrollee requested authorization and coverage of a bilateral mastectomy with ultrasound and suction-assisted lipectomy. The Health Plan denied the request indicating that the procedure is cosmetic in nature and not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is cosmetic in nature and not medically necessary.

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


Answer: A 43-year-old male enrollee requested authorization and coverage of a nebulizer. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees asthma.

Context: A 43-year-old male enrollee requested authorization and coverage of a nebulizer. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees asthma.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.

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


Answer: A 35-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.

Context: A 35-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.

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


Answer:
A 31-year-old female has requested reimbursement for lab tests that measure the levels of
medication, adalimumab (ADA) performed on 8/1/22. The Health Insurer has denied this request
indicating that the testing at issue was considered investigational for evaluation of the insureds
ulcerative colitis.

Context:
Summary Reviewer 3
A 31-year-old female has requested reimbursement for lab tests that measure the levels of
medication, adalimumab (ADA) performed on 8/1/22. The Health Insurer has denied this request
indicating that the testing at issue was considered investigational for evaluation of the insureds
ulcerative colitis. The physician reviewer found that on review of the current peer-reviewed
medical literature, the drug assay testing for ADA performed on 8/1/22 was likely to be more
beneficial for the evaluation of this patient than any available standard therapy. The drug testing
performed was reactive drug monitoring since the test was recommended in response to the
patients symptoms of ulcerative colitis. The most recent national guideline from the AGA
specifically  endorses  reactive  drug  monitoring  in  this  clinical  setting  when  the  patient  has
symptoms while on anti-TNF agents such as ADA (Feuerstein, et al.). The AGA guidelines cite
data that has shown that reactive drug monitoring is more beneficial than standard therapy
including  change of  drug therapy without the drug  assay  and  is  supported with  consensus
agreement among experts (Feuerstein, et al.; Papamichael, et al.). Thus, the lab tests that measure
the levels of adalimumab performed on 8/1/22 was likely more beneficial for evaluation of the
patient than any available standard therapy.

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


Answer: A 63-year-old female enrollee has requested reimbursement for ExoSym kinetic orthosis for right knee provided on 9/12/16. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees right knee pain.

Context:
Summary Reviewer 1

A 63-year-old female enrollee has requested reimbursement for ExoSym kinetic orthosis for right knee provided on 9/12/16. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees right knee pain. The physician reviewer found that the ExoSym kinetic orthosis is a customizable energy-storing device that is designed to support and protect an array of lower extremity limb injuries. However, at this time, there is a lack of evidence to support that the published results can be duplicated on a reliable basis. Until quality data becomes available, this orthosis does not have adequate support for use outside of a clinical trial. Accordingly, the ExoSym kinetic orthosis for right knee provided on 9/12/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 47-year-old female enrollee has requested reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck and shoulder pain.

Answer: In this case

Answer: the patient presented with

Answer: pain

Answer: Per 10/19/15 report, the patient was instructed to use ice as needed and to take NSAIDs at her discretion. The patients diagnosis on 7/6/16 included cervicalgia and pain in right shoulder.

Context:
Summary Reviewer

A 47-year-old female enrollee has requested reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck and shoulder pain. The physician reviewer found that the American College of Occupational and Environmental Medicine (ACOEM) state that if manipulation does not bring improvement in three to four weeks, it should be stopped and the patient reevaluated. In this case, while the patient presented with subjective pain, the provider has not documented clinical assessments and evaluations to support continued treatments. Most importantly, the records do not include discussions on objective functional improvement as an indication for the extended duration of care. Per 10/19/15 report, the patient was instructed to use ice as needed and to take NSAIDs at her discretion. The patients diagnosis on 7/6/16 included cervicalgia and pain in right shoulder. Overall, the medical necessity for continued chiropractic care cannot be determined without documentation of objective functional improvement. Therefore, reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16 were not medically necessary for treatment of this patients medical condition. Based on the records provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

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


Answer:
A 27-year-old female enrollee has requested authorization and coverage for E1399 durable
medical equipment RT300 FES arm therapy system. The Health Insurer has denied this request
and reported that the requested device is investigational for the treatment of the enrollees
medical condition.

Context:
Summary Reviewer 2

A 27-year-old female enrollee has requested authorization and coverage for E1399 durable
medical equipment RT300 FES arm therapy system. The Health Insurer has denied this request
and reported that the requested device is investigational for the treatment of the enrollees
medical condition. The physician reviewer found that the E1399 RT300 FES arm therapy system
is not likely to be more beneficial than other available standard therapy. It is uncertain whether
FES  can  restore  upper-extremity  function  or  improve  the  quality  of  life.  The  evidence  is
insufficient to determine the effects of the technology on health outcomes. The evidence for the
effectiveness of the RT300 FES cycling in people with stroke is limited. There is insufficient
evidence in the literature that supports that the use of the RT300 FES will be effective for this
patients hemiplegia from stroke in long-term improvement of muscle strength, vascular blood
flow, bone mineral density, reduction of spasticity and atrophy, facilitation of functional motor
movement  or  reduction  muscle  atrophy  in  the  upper  and  lower  extremities.  Eraifej  and
colleagues performed a meta-analysis of 20 studies on the benefits of FES on activities of daily
living. Only three studies showed a significant benefit of FES on activities of daily living when
initiated within two months post-stroke. In three studies where FES was initiated more than one
year after stroke, no significant activities of daily living improvements were seen. Limitations of
the evaluable studies included, very low quality evidence in all analyses due to heterogeneity,  low participant numbers and lack of blinding. The authors concluded that FES is a promising
therapy that could play a part in future stroke rehabilitation. They noted that there is a need for
high quality large-scale randomized controlled trials of upper limb FES after stroke to draw firm
conclusions regarding its efficacy or its optimum therapeutic window. The evidence that FES
cycling can have a long-term effect on bone mineral density is not found in the literature. An
additional study done on the prevention and treatment of osteoporosis by Soleyman-Jahi and
colleagues revealed very low-quality evidence that low-intensity cycling (three days per week)
with FES provided a benefit for reducing bone mineral density loss in individuals with chronic
spinal  cord  injury  or  neurologic  injury.  All  told,  the  current  medical  evidence  has  not
demonstrated the superior efficacy of the requested device. Therefore, the requested for E1399
durable medical equipment RT300 FES arm therapy system is not likely to be more beneficial
than any available standard therapy.

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


Answer: A 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/7/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees breast cancer examination.

Context:
Summary Reviewer 1

A 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/7/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees breast cancer examination.  The physician reviewer found that the American College of Radiology urged tomosynthesis be removed from the investigational category in 2014 due to the advantage it brings radiologists interpreting mammograms especially in patients with dense breasts such as the patient under review. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural disorder resulting in a decrease in callbacks and increase in detection of small cancers compared to two-dimensional (2D) imaging alone. In this case, the use of tomosynthesis likely aided the radiologist to detect the area of interest in the left breast in this patient with dense breast tissue. Thus, the addition of tomosynthesis was likely of greater benefit to the patient than had her exam been done with 2D imaging alone. For this reason, the digital breast tomosynthesis performed on 10/7/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: A 58-year-old female enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1b.

Context:
Summary Reviewer

A 58-year-old female enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1b.  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

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


Answer: A 57-year-old female enrollee has requested reimbursement for testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.

Answer: this patients family history is suggestive of a breast/ovarian cancer syndrome.

Context:
Summary Reviewer 3

A 57-year-old female enrollee has requested reimbursement for testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patients family history is suggestive of a breast/ovarian cancer syndrome. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer tumors in families. The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed, in no particular order, by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral. The MyRisk panel is appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Thus, testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19 was likely to have been more beneficial than other methods of evaluating this patient.

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


Answer: A 52-year-old female enrollee has requested reimbursement for computed tomography (CT) scan of the sinuses performed on 1/12/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition.

Context:
Summary Reviewer

A 52-year-old female enrollee has requested reimbursement for computed tomography (CT) scan of the sinuses performed on 1/12/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical literature supports the use of CT scan in diagnosis and treatment planning in the setting of chronic recurrent rhinosinusitis.  However, it is not within standard of care to repeat a scan in this clinical setting.  There is no medical indication for this patient to have undergone a second CT one month after a prior scan showed lack of disease.  All told, the CT scan of the sinuses performed on 1/12/16 was not medically indicated in this particular situation.  Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.

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


Answer:
The patient is a 73-year-old male who presented to his provider on 5/11/23. The records noted that
the patient initially presented with an elevated prostate-specific antigen of 6.5 ng/mL in 2019. The
patient has requested authorization and coverage for PBRT. The Health Insurer has denied this
request and reported that the requested service is not medically necessary for the treatment of this
patient.

Context:
Summary
The patient is a 73-year-old male who presented to his provider on 5/11/23. The records noted that
the patient initially presented with an elevated prostate-specific antigen of 6.5 ng/mL in 2019. The
patient has requested authorization and coverage for PBRT. The Health Insurer has denied this
request and reported that the requested service is not medically necessary for the treatment of this
patient. This denial is the subject of this appeal and determination. The physician reviewer found
that the submitted documentation does not support the medical necessity of the requested service
Proton beam has unique properties compared to standard photon or x-ray beam in its ability to
deposit radiation doses. The use of proton beams potentially results in fewer areas of low scattered
radiation dose as fewer proton beams may be used to achieve a dose distribution similar to standard
photon beams. Proton therapy is currently utilized and strongly indicated in settings where severe
toxicities would result if normal tissue constraints cannot be met by photon beam. However, in the
setting of localized prostate cancer, there has not been a demonstrable clinically significant
improvement in either quality of life or reduction of high-grade toxicities. Studies in current
medical literature have not demonstrated a significant difference in overall survival nor normal
tissue toxicities over photon beam in the treatment of prostate cancer. These data question the
utility of proton beam radiation particularly for patients with localized disease. There are ongoing
prospective trials investigating the potential benefits in disease outcomes and toxicities, however,
no definite benefit has been demonstrated for proton beam at this time. While proton therapy may
be medically indicated in some cases of unusual anatomy or in cases of re-irradiation of adjacent
tissues, this is not the case for this particular patient. In this clinical setting, given this patients
medical history and the nature of his prostate cancer diagnosis, the requested service is not
medically indicated. Therefore, PBRT is not medically necessary for the treatment of this patient.

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


Answer: A 62-year-old female has requested authorization and coverage for spine nerve treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees back pain.

Answer: Per the records, this patient has received

Answer: a single set of diagnostic lumbar medial branch blocks.

Context:
Summary Reviewer 1

A 62-year-old female has requested authorization and coverage for spine nerve treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees back pain. The physician reviewer found the current medical evidence does not support the requested services in this clinical setting.  Per the records, this patient has received only a single set of diagnostic lumbar medial branch blocks. Manchikanti and colleagues noted the evidence for diagnostic lumbar facet joint nerve blocks and diagnostic sacroiliac intraarticular injections is good with 75% to 100% pain relief as criterion standard with controlled local anesthetic or placebo blocks. Additionally, the literature supports the use of a second set of diagnostic medial branch blocks. In this patients case, the pain relief did not exceed 75%, and a second set of diagnostic medial branch blocks was not performed. Therefore, the requested spine nerve treatment is not likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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