Answer: A 48-year-old female enrollee has requested authorization and coverage for implantation of Strattice. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees abdominal hernia.

Answer: the patient has failed standard therapy for correction of her complex abdominal hernia.  She has failed primary repair with synthetic mesh, as the mesh had become infected and had to be removed. This patient has evidence of a symptomatic, recurrent, left lower abdominal hernia.  She has a history of severe trauma and multiple reconstructive procedures of her abdomen.  She has noted to have failed previous mesh placement, as it had become infected and had to be removed.  Currently, she is symptomatic from her hernia with chronic pain, treated with an abdominal binder and chronic opioid use.

Context:
Summary Reviewer 1
A 48-year-old female enrollee has requested authorization and coverage for implantation of Strattice. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees abdominal hernia. The physician reviewer found that there is support in the literature for the efficacy of the requested services in this clinical setting. Based on the overall documentation provided for review, the patient has failed standard therapy for correction of her complex abdominal hernia.  She has failed primary repair with synthetic mesh, as the mesh had become infected and had to be removed. This patient has evidence of a symptomatic, recurrent, left lower abdominal hernia.  She has a history of severe trauma and multiple reconstructive procedures of her abdomen.  She has noted to have failed previous mesh placement, as it had become infected and had to be removed.  Currently, she is symptomatic from her hernia with chronic pain, treated with an abdominal binder and chronic opioid use.  The requested Strattice (porcine biologic mesh) is used to reinforce the abdominal reconstruction provided by autologous tissue.  Strattice is a bioprosthetic porcine mesh. The medical literature indicates that bioprosthetic materials are preferred over synthetic materials for use in contaminated fields and should be strongly considered when the defect has bacterial contamination.  Patel and colleagues noted, Strattice is an effective adjunct to AWR (abdominal wall reconstruction) when used as reinforcement during CS (component separation) for a wide variety of indications. Complication rates remain low in complex patients. In addition, Strattice appears to add durability to midline reconstructions with no recurrences during the follow-up period.  In summary, this patient has exhausted standard therapy and Strattice has been shown to provide benefit in abdominal wall reconstruction. As such, implantation of Strattice is likely to be superior to the standard options available for treatment of this patients medical condition.Therefore for the reasons stated above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: A 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic.

Context:
Summary Reviewer 1

A 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that there is sufficient support for the service at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: A 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic.

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

Context:
Summary Reviewer 3

A 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts have been described as extremely dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  In sum, digital breast tomosynthesis performed on 8/01/16 was likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: A 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency.

Context:
Summary Reviewer 3

A 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency. The physician reviewer found that intractable lower urinary tract symptoms and painful bladder/urethral syndrome related to interstitial cystitis can be clinically difficult to treat. Treatment options often are limited and have variable results. Patients often receive multimodal treatment, including proceeding to secondary and tertiary treatment options. Percutaneous tibial nerve stimulation is considered as a tertiary treatment option for intractable lower urinary tract symptoms and painful bladder syndrome with urgency frequency syndrome. There is some support for the requested services in this clinical setting. Therefore, nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18 was likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer:
A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous
basivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating
that the requested services are considered investigational for treatment of the insureds chronic
low  back  pain.

Answer:
This
patients MRI of the lumbar spine demonstrated fibrotic type endplate change at L4-5

Answer:
the patients
MRI also showed mild central and moderate left paracentral disc protrusion, moderate left lateral
recess stenosis, mild right and moderate left foraminal narrowing secondary to disc protrusion
and mild central canal stenosis.

Context:
Summary Reviewer 1

A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous
basivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating
that the requested services are considered investigational for treatment of the insureds chronic
low  back  pain.  The  physician  reviewer  found  that  according  to  the  U.S.  Food  and  Drug
Administration (FDA), intraosseous nerve ablation is intended to be used in conjunction with
radiofrequency for the ablation of basivertebral nerves for the relief of chronic low back pain of
at least six months duration that has not responded to at least six months of conservative care
and is also accompanied by features such as disruption and fissuring of the endplate. This
patients MRI of the lumbar spine demonstrated fibrotic type endplate change at L4-5 that would
make the patient a good candidate for ablation of basivertebral nerves. However, the patients
MRI also showed mild central and moderate left paracentral disc protrusion, moderate left lateral
recess stenosis, mild right and moderate left foraminal narrowing secondary to disc protrusion
and mild central canal stenosis. Thus, there are multiple plausible pathologic sources of low back
pain and finding the source of chronic lower back pain is clinically challenging (Tieppo Francio
and Sayed). A small minority low back pain diagnoses can be attributed to an anatomical source.
Overall, the medical evidence is insufficient to support a finding of spinal vertebral bodies as
being the overwhelming primary generators of the patients chronic low back pain. Therefore,
the requested intraosseous basivertebral nerve ablation (CPT code 64628) is not likely to be more
beneficial than any other available standard treatments for the patients medical condition.

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


Answer:
A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous
basivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating
that the requested services are considered investigational for treatment of the insureds chronic
low back pain.

Answer:
This
patient  presents  with  more  than  six  months  of  chronic  axial  low  back  pain.  MRI  results
demonstrated changes at disc space endplates L4-5. This patient has undergone more than six
months of conservative treatment consisting of intradiscal steroid injection, home exercise and
physical therapy. Gabapentin, meloxicam and methocarbamol have failed to provide sufficient
and  durable  relief.

Context:
Summary Reviewer 3

A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous
basivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating
that the requested services are considered investigational for treatment of the insureds chronic
low back pain. The physician reviewer found that basivertebral nerve ablation is a minimally
invasive outpatient procedure allowing for a quick recovery. The procedure is implant-free and
preserves  spinal  integrity  by  negating  need  for  extensive  tissue  exposure  and  disruption.
Additionally, basivertebral nerve ablation fills a treatment gap for patients with chronic low back
pain and preserves future treatment options. In one study, patients with chronic low back pain
who underwent basivertebral nerve ablation reported significant improvement in pain and
function with well documented long-term effectiveness and durability (Fischgrund, et al.). This
patient  presents  with  more  than  six  months  of  chronic  axial  low  back  pain.  MRI  results
demonstrated changes at disc space endplates L4-5. This patient has undergone more than six
months of conservative treatment consisting of intradiscal steroid injection, home exercise and
physical therapy. Gabapentin, meloxicam and methocarbamol have failed to provide sufficient
and  durable  relief.  This  patient  does  not  warrant  more  invasive  treatment,  such  as
decompression and fusions, as there are no reported severe symptoms of lumbar radiculopathy.
Given these findings the requested intraosseous basivertebral nerve ablation (CPT code 64628)
is likely to be more beneficial than any other available standard treatments for the patients
medical condition.

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


Answer: The patient is a 56-year-old transgender female who has been diagnosed with gender dysphoria. The patient has requested authorization and coverage for facial feminization surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.

Context:
Summary Reviewer

The patient is a 56-year-old transgender female who has been diagnosed with gender dysphoria. The patient has requested authorization and coverage for facial feminization surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, aimproved mental health-related quality of life.a The World Professional Association for Transgender Health position statement states, aNon-genital surgical proceduresanotably facial feminization surgeryaare often of greater practical significance in the patientas daily life than reconstruction of the genitalsaThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.a There is sufficient support for the requested services in this patientas case. Therefore, the requested facial feminization surgery is medically necessary for the treatment of this patient.

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


Answer: The parent of a one-year-old male enrollee has requested reimbursement for inpatient hospital level of care provided on 3/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD).

Answer: the patient was a five-month-old ex-premature infant who was approximately 44 weeks post conceptual age at the time that he presented for apnea and cyanosis associated with vomiting for which he was treated with back blows by his mother. The apneic episode resolved by the time of presentation to the hospital and he appeared to be healthy when evaluated by the provider. He was admitted for observation and cardiopulmonary monitoring. He was diagnosed with an apparent life threatening event (ALTE) due to gastroesophageal reflux disease (GERD). Other than monitoring, he received a suppository to treat constipation. He had no further apnea or cyanosis in the hospital. He tolerated oral intake without emesis. He remained well appearing and had no signs of acute illness.

Context:
Summary Reviewer

The parent of a one-year-old male enrollee has requested reimbursement for inpatient hospital level of care provided on 3/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD).  The physician reviewer found the patient was a five-month-old ex-premature infant who was approximately 44 weeks post conceptual age at the time that he presented for apnea and cyanosis associated with vomiting for which he was treated with back blows by his mother. The apneic episode resolved by the time of presentation to the hospital and he appeared to be healthy when evaluated by the provider. He was admitted for observation and cardiopulmonary monitoring. He was diagnosed with an apparent life threatening event (ALTE) due to gastroesophageal reflux disease (GERD). Other than monitoring, he received a suppository to treat constipation. He had no further apnea or cyanosis in the hospital. He tolerated oral intake without emesis. He remained well appearing and had no signs of acute illness. The medical literature supports hospitalization for observation for cardiopulmonary monitoring for 23 hours after an ALTE in the majority of infants (Fu and Moon; McGovern and Smith). However, certain individuals can be discharged from the emergency department without hospitalization (Kahn and European Society for the Study and Prevention of Infant Death). Given that the patient was well-appearing at the time of presentation, had no further events during observation in the hospital, did not require specific interventions or extensive evaluation beyond observation, and was discharged home on the same day of admission, he met criteria for observation but not admission. Based upon the information provided and reviewed and the medical literature reviewed, the inpatient hospital level of care provided on 3/31/16 was not medically necessary for treatment of the patients medical condition. For the reasons 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 42-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/29/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees melanoma.

Context:
Summary Reviewer 3

A 42-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/29/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees melanoma. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 8/29/18 was not likely to have been of greater benefit than other methods of evaluating this patient.

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


Answer:
A 28-year-old female insured has requested authorization and coverage for intravenous (IV)
Gammagard. The Health Insurer has denied this request indicating that the requested treatment is
considered investigational for the treatment of the insured's refractory relapsing polychondritis.

Answer:
In this case, the patient
presents with relapsing polychondritis.

Answer:
the patient
has tried and failed treatment with multiple therapies from several classes of medications. The
provider has recommended a continuation of IVIG therapy

Context:
Summary Reviewer 3
A 28-year-old female insured has requested authorization and coverage for intravenous (IV)
Gammagard. The Health Insurer has denied this request indicating that the requested treatment is
considered investigational for the treatment of the insured's refractory relapsing polychondritis.
The physician reviewer found that there is limited medical literature studying IVIG as a treatment
option for patients with relapsing polychondritis. Relapsing polychondritis is a rare autoimmune
disorder, and official guidelines to utilize certain therapies are not likely to be available in the near
future. However, for patients who have tried and failed treatment with multiple therapies from
several classes of medications, IVIG is appropriate as the next-line treatment option. This is
particularly applicable when its efficacy has been established for a particular patient in keeping
the disease stable or in remission. According to one study by Lekpa and Chevalier, IVIG has been
shown to be effective in some patients with relapsing polychondritis. In this case, the patient
presents with relapsing polychondritis. The records provided for review indicate that the patient
has tried and failed treatment with multiple therapies from several classes of medications. The
provider has recommended a continuation of IVIG therapy which has already been shown to be
the most effective treatment option for this patient. All told, the requested IV Gammagard is likely
to be more beneficial for the treatment of the patients condition than any available standard
therapy.

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


Answer: A 55-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 1/24/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.

Context:
Summary Reviewer 3

A 55-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 1/24/19. 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 once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features, such as the grade of tumor and prostate-specific antigen (PSA) level. This helps guide the most appropriate therapy for patients taking into account their age and comorbidities, because many patients will not require therapy (i.e., surgery or radiation) and may be followed closely instead. Oncotype DX Prostate testing is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score. The current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients. Oncotype DX Prostate testing is an appropriate test in this context. The National Comprehensive Cancer Network guidelines also suggest the use of this test to better stratify such patients with localized disease. Thus, Oncotype DX Prostate testing performed on 1/24/19 was likely to have been more beneficial than any available standard therapy.

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


Answer: A 67-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy performed on 7/19/16. The Health Plan has denied this request indicating that the service at issue is considered investigational for treatment of the enrollee breast cancer.

Context:
Summary Reviewer 1

A 67-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy performed on 7/19/16. The Health Plan has denied this request indicating that the service at issue is considered investigational for treatment of the enrollee breast cancer. The physician reviewer found that there is a lack of medical literature supporting the service at issue in this clinical setting. Silverstein and colleagues studied intraoperative radiotherapy for early-stage breast cancer. The study revealed that intraoperative radiotherapy was associated with a nine-fold increase in ipsilateral breast recurrence, although five-year overall survival was similar. In addition, the American Society for Radiation Oncology (ASTRO) consensus guidelines recommended intraoperative radiation therapy for those with suitable criteria with invasive cancer, and not for patients with DCIS. Moreover, treatment with intraoperative radiation therapy is not the standard therapy for breast cancer. Given the lack of support in the peer-reviewed literature, the intraoperative radiation therapy performed on 7/19/16 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 service 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: The patient is a 19-year-old female with anorexia nervosa, post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder. She was admitted to a residential treatment center on 12/23/19.

Answer: The records noted a past history of multiple suicide attempts, and she expressed suicidal ideation at the residential treatment center.

Answer:
The records noted
moderate impairment due to troubled relationships with parents and lack of employment or school attendance prior to admission.

Context:
Summary Reviewer

The patient is a 19-year-old female with anorexia nervosa, post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder. She was admitted to a residential treatment center on 12/23/19. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. With regards to risk of harm, the records support a score of 4. The records noted a past history of multiple suicide attempts, and she expressed suicidal ideation at the residential treatment center. In terms of functional status, the records support a score of 3. The records noted
moderate impairment due to troubled relationships with parents and lack of employment or school attendance prior to admission. With regard to comorbidity, the records support a score of 3 due to the physical manifestations of anorexia nervosa, including low weight and laboratory abnormalities, co-occurring with post-traumatic stress disorder, depression, and anxiety symptoms. In terms of level of stress of the recovery environment, the records support a score of 3 due to discord with parents and recent transition back to the United States after a year of living abroad. With regard to level of support of the recovery environment, the records support a score of 3 due to parents ambivalence toward participating in treatment and lack of recent contact with the patient. In terms of treatment and recovery history, the records support a score of 4 due to the persistence of symptoms despite prior extensive treatment. With regard to engagement and recovery status, the records support a score of 3 due to poor insight and limited judgment. Thus, the patient has a composite score of 23. In this case, the records support medically monitored residential services. Therefore, eating disorder residential treatment center services from 1/23/20 forward were and are medically necessary for the treatment of this patient.

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


Answer: A 30-year-old female enrollee has requested reimbursement for bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition.

Context:
Summary Reviewer 2

A 30-year-old female enrollee has requested reimbursement for bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the non-surgical treatment is the initial treatment of choice for symptomatic hallux valgus deformity. Shoe modification, padding and local application of ice to symptomatic bunion are reasonable initial conservative options. Orthotic devices to control documented biomechanical dysfunction may be considered as conservative or post-surgical options. Surgical treatment is recommended if there is no or little response to non-operative treatment after a six-month trial, or if initial response deteriorates. In general, once surgical criteria has been met, the surgical procedures to be performed are based on the location and the degree of deformity. The two most common radiographic measurement used to choose appropriate surgical procedures include the intermetatarsal angle (IMA) and the hallux valgus angle (HVA). For IMAs less than 13 degrees, distal osteotomy or soft tissue procedure alone are sufficient to correct the deformity. For IMAs greater than 13 degrees, a proximal osteotomy is recommended. There is a variety of osteotomies described to correct the IMA, including the scarf, and no procedure has proved superiority over the other. Regarding the HVA, angles less than 30 degrees can be treated with a distal soft tissue procedure, such as the modified McBride procedure, with or without a chevron osteotomy. For HVA greater than 40 degrees, metatarsophalangeal joint fusion is generally recommended.
In this patients case, operative criteria have been met. Based on the radiographs and the HVA and IMA measurements reported by the treating surgeon, appropriate surgical procedures were performed and are supported by published treatment guidelines for the treatment of symptomatic hallux valgus. In sum, bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19 was likely to have been more beneficial than other treatment options.

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


Answer: A 60-year-old male enrollee has requested reimbursement for chiropractic services including CPT codes 97110, 97032, 97140 and 99214 provided on 6/1/17, 6/8/17, 6/15/17, 8/14/17, and 9/7/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees spondylosis without myelopathy/radiculopathy of the cervical region.

Context:
Summary Reviewer

A 60-year-old male enrollee has requested reimbursement for chiropractic services including CPT codes 97110, 97032, 97140 and 99214 provided on 6/1/17, 6/8/17, 6/15/17, 8/14/17, and 9/7/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees spondylosis without myelopathy/radiculopathy of the cervical region. The physician reviewer found that the provided documentation does not establish the medical necessity of the chiropractic services provided from 6/1/17 through 9/7/17. Specifically, the records do not objectively verify functional improvements with prior chiropractic therapy over eight weeks of care. As noted in the current medical literature and guidelines, the documentation should report objective functional improvement with chiropractic treatment to support an indication for future services. Accordingly, the chiropractic services including CPT codes 97110, 97032, 97140 and 99214 provided on 6/1/17, 6/8/17, 6/15/17, 8/14/17, and 9/7/17 were not medically necessary for treatment of this patients neck pain and low back pain. Based on the foregoing discussion, 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 55-year-old female enrollee has requested reimbursement for inpatient hospital services provided from 3/01/18 through 3/02/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who reported chest tightness and dyspnea.

Answer: This patient presented with unforeseen symptoms possibly due to coronary ischemia associated with an abnormal electrocardiogram and normal initial troponin value.

Answer: the patient was clinically stable after initial evaluation

Context:
Summary Reviewer

A 55-year-old female enrollee has requested reimbursement for inpatient hospital services provided from 3/01/18 through 3/02/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who reported chest tightness and dyspnea. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient presented with unforeseen symptoms possibly due to coronary ischemia associated with an abnormal electrocardiogram and normal initial troponin value. In this circumstance, a period of overnight observation without hospital admission is reasonable and appropriate to confirm no evidence of myocardial infarction with serial troponins prior to discharge. Since the patient was clinically stable after initial evaluation, with an anticipated length of stay of less than 48 hours or less than two midnights, hospital admission was not medically necessary. Based on the records, an observational level of stay would have been safe and effective. Thus, inpatient hospital services provided from 3/01/18 through 3/02/18 were not medically necessary for the treatment of this patient. Therefore, 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 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.

Context:
Summary Reviewer 1

A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.The physician reviewer found in this case, the medical records fail to indicate any diagnosis consistent with an IgG mediated food allergy to support an indication for the testing at issue. The current National Institutes of Health National Institute of Allergy and Infectious Disease expert panel states that IgG food testing is not validated (Boyce, et al). The Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated (Sampson, et al). As such, IgG food testing is not considered the standard of care in this clinical setting (Sicherer and Teuber). Thus, the IgG food sensitivity testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.

Context:
Summary Reviewer 3

A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.  The physician reviewer found the use of food-specific IgG level testing has not been shown to improve health outcomes at long-term follow-up. There is data suggesting that this testing does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods (Beyer and Teuber). Thus, food-specific IgG should not be used as a tool to diagnose food allergy and the positive foods should not be eliminated from the diet based upon results of these tests (Lemon-Mule, et al; Savilahti, et al). The standard evaluation of food allergy consists of blood IgE level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum. Immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens including egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95%. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. A negative skin test result indicates the absence of an IgE-mediated allergy upon subsequent challenge with a 90 to 95% predictive accuracy. In conclusion, the IgG food laboratory testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard of care.Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 51-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 5/23/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who reported bilateral breast tenderness.

Context:
Summary Reviewer 1

A 51-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 5/23/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who reported bilateral breast tenderness. The physician reviewer found there is sufficient support for the service at issue in this clinical setting.  Skaane and colleagues noted the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues indicated integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  The literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis performed on 5/23/16 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer:
The patient is a 52-year-old female with psoriasis and psoriatic arthritis affecting her skin including
on her palms and soles. The patient has requested authorization and coverage for Cosentyx two
pens 150 mg/ml pen injector. The Health Insurer has denied this request and reported that the
requested medication is not medically necessary for the treatment of this patient.

Context:
Summary Reviewer
The patient is a 52-year-old female with psoriasis and psoriatic arthritis affecting her skin including
on her palms and soles. The patient has requested authorization and coverage for Cosentyx two
pens 150 mg/ml pen injector. The Health Insurer has denied this request and reported that the
requested medication is not medically necessary for the treatment of this patient. This denial is the
subject of this appeal and determination. The physician reviewer found Cosentyx is a U.S. Food
and Drug Administration (FDA) approved medication for the treatment of psoriasis.  It receives
an A rating from the American Academy of Dermatology and National Psoriasis Foundation
guidelines of care. This medication has good safety and efficacy profiles. It is recommended as
treatment for chronic psoriasis by the American Academy of Dermatology and National Psoriasis
Foundation. It has been shown in the FIXTURE study to be a safe and efficacious medication for
the treatment of psoriasis. The requested medication is medically indicated for the treatment of
this patients chronic psoriasis, psoriatic arthritis and hand and foot psoriasis. Therefore, Cosentyx
two pens 150 mg/ml pen injector is medically necessary for the treatment of this patient.

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


Answer: A 60-year-old female enrollee has requested reimbursement for the emergency department services provided at Hoag Hospital on 12/1/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis.

Answer: The patient was directed to go to the emergency department by her primary care provider to rule out diverticulitis. She was evaluated and found to have diverticulitis, was offered admission, and declined. She was prescribed oral antibiotics.

Answer: The patient then left and went to the second emergency department. There she received one dose of intravenous antibiotics and was discharged.

Context:
Summary Reviewer

A 60-year-old female enrollee has requested reimbursement for the emergency department services provided at Hoag Hospital on 12/1/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patients symptoms on 12/1/16 did meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his or her health. The patient was directed to go to the emergency department by her primary care provider to rule out diverticulitis. She was evaluated and found to have diverticulitis, was offered admission, and declined. She was prescribed oral antibiotics. The medical records support a comprehensive history and medical decision making of high complexity to support CPT code 99285. The patient then left and went to the second emergency department. There she received one dose of intravenous antibiotics and was discharged. All told, the emergency department services provided at Hoag Hospital on 12/1/16 were required on an emergent basis and include comprehensive history and medical decision making of high complexity to support CPT code 99285. Therefore, the Health Insurers denial should be overturned.

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


Answer: The patient is a 47-year-old female who presented to her primary care provider on 7/25/19 for establishment of care. The patient has requested reimbursement for vitamin D testing performed on 7/30/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient.

Context:
Summary Reviewer

The patient is a 47-year-old female who presented to her primary care provider on 7/25/19 for establishment of care. The patient has requested reimbursement for vitamin D testing performed on 7/30/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that the clinical manifestations of vitamin D deficiency depend upon the severity and duration of the deficiency. The majority of patients with moderate to mild vitamin D deficiency are asymptomatic. With severe vitamin D deficiency, there can be hypocalcemia, which leads to bone disorders.   Patient groups who are at risk for vitamin D insufficiency include those who have dark skin or are obese, those taking medications that accelerate the metabolism of vitamin D, hospitalized or institutionalized people or those who have limited effective sun exposure. Other people at high risk include those with osteoporosis or malabsorption, including inflammatory bowel disease and celiac disease. Screening of the general population is not recommended. Normal-risk adults do not need assessment. In this case, the patient does not have any chronic medical conditions that would cause vitamin D deficiency. She did not have any signs or symptoms of vitamin D toxicity or severe deficiency. Therefore, vitamin D testing performed on 7/30/19 was not medically necessary for the evaluation of this patient.

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


Answer: A 51-year-old female has requested reimbursement for human epididymis protein 4 (HE4) testing.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.

Context:
Summary Reviewer 1

A 51-year-old female has requested reimbursement for human epididymis protein 4 (HE4) testing.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case.  HE4 is used for the evaluation of an adnexal mass as a component of the Risk of Ovarian Malignancy Algorithm (ROMA). A ROMA score helps determine the likelihood that an adnexal mass is malignant and the need for referral to a gynecologic oncologist for surgery. This testing is considered a standard of care.  In sum, HE4 testing performed on 11/20/15 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were 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 65-year-old male enrollee has requested reimbursement for collagen crosslink testing performed on 7/11/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.

Answer: This patient has received Prolia.

Context:
Summary Reviewer 3

A 65-year-old male enrollee has requested reimbursement for collagen crosslink testing performed on 7/11/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  This patient has received Prolia.  In this clinical setting, a dual-energy x-ray absorptiometry (DEXA) scan is appropriate to monitor therapy.  The value of monitoring therapy with the use of biochemical markers of bone turnover is controversial.  This is a test that can be variable and subject to timing, dietary intake and lack of assay standardization.  In sum, collagen crosslink testing performed on 7/11/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 46-year-old female enrollee has requested authorization and coverage for CPT 19316 performed on 10/24/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition.

Answer: This patient had evidence of significant symptomatic macromastia, and she had failed conservative management. Based on the documentation provided, she was a candidate for bilateral breast reduction based on non-resolving functional impairment. She underwent this procedure on 10/24/18. The operative note was consistent with a standard breast reduction and not solely a mastopexy.

Context:
Summary Reviewer

A 46-year-old female enrollee has requested authorization and coverage for CPT 19316 performed on 10/24/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had evidence of significant symptomatic macromastia, and she had failed conservative management. Based on the documentation provided, she was a candidate for bilateral breast reduction based on non-resolving functional impairment. She underwent this procedure on 10/24/18. The operative note was consistent with a standard breast reduction and not solely a mastopexy. Generally, standard breast reductions include a breast lift as an integral part of the procedure and would not be considered a separate procedure. Based on the documentation provided, this patient underwent a bilateral breast reduction and not solely a mastopexy. An additional mastopexy would not be considered as a separate procedure, but an integral portion to the breast reduction. Therefore, the Health Insurers denial was appropriate. Thus, mastopexy (CPT 19316) performed on 10/24/18 was not medically necessary for the treatment of this patient.

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


Answer: A 62-year-old male enrollee has requested reimbursement for the Life Vest provided from 6/10/15 through 7/10/15. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees dilated cardiomyopathy.

Context:
Summary Reviewer 2

A 62-year-old male enrollee has requested reimbursement for the Life Vest provided from 6/10/15 through 7/10/15. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees dilated cardiomyopathy. The physician reviewer found that placement of a prophylactic defibrillator is not recommended until a period of time after myocardial infarction has elapsed, where continued severe left ventricular dysfunction is documented to persist in spite of appropriate treatment (Russo, et al). Placement of a prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve patient outcomes. Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction of 35% or less before ventricular function has had a chance to recover have not demonstrated improved outcome (Steinbeck, et al). A prophylactic wearable external defibrillator is indicated only if accepted criteria for an implantable defibrillator are met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. Therefore, the Life Vest provided from 6/10/15 through 7/10/15 has not been demonstrated by scientific literature as likely to have been more beneficial in treating this patients medical condition than standard alternatives. Based upon the information set forth above, I have determined 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 male enrollee has requested reimbursement for the Oncotype Dx Colon Cancer Assay provided on 2/14/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectosigmoid cancer.

Context:
Summary Reviewer 2

A 47-year-old male enrollee has requested reimbursement for the Oncotype Dx Colon Cancer Assay provided on 2/14/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectosigmoid cancer. The physician reviewer found that the Oncotype DX test uses a reverse transcriptase polymerase chain reaction assay for 12 genes in an algorithm that can be used to help predict recurrence (OConnell, et al; Gray, et al). Despite this support, it has not been established whether adjuvant chemotherapy can obviate recurrence risk. Overall, the current data does not support use of the Oncotype DX as a predictive marker for response to adjuvant treatment (Benson and Hamilton; Gray, et al). As such, the National Comprehensive Cancer Network (NCCN) guidelines state that there are insufficient data to recommend use of multi-gene assay panels to determine adjuvant therapy. All told, the Oncotype DX Colon Cancer Assay provided on 2/14/18 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 31-year-old female enrollee has requested reimbursement for inpatient mental health services provided from 11/7/17 to 12/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder and depression.

Answer: The patient presented with significant risk of harm

Answer: with a history of a suicide attempt at age 15 by attempting to overdose on Advil. The patient also has a history of self-cutting from the ages of 14-19 years old. On 11/7/17 and several days prior, the patient had intermittent passive suicidal thoughts. The patient demonstrated moderate functional impairment

Answer: and due to her symptoms, the patient was unable to fulfill her responsibilities in her work. The patient showed significant co-morbidity

Answer: with history of bipolar II, cluster B traits, and bingeing, purging, and restricting behaviors. The patient did not have substance abuse problems. The patients recovery environment is mildly stressful

Answer: as she demonstrated distress while she was traveling in Paris due to isolation. The patients recovery environment was supportive

Answer: and she demonstrated moderate response to prior treatment

Answer: The patient demonstrated positive engagement and recovery

Answer: as she was described as attentive and engaged during treatment. The patient had a positive attitude toward recovery and treatment.

Context:
Summary Reviewer

A 31-year-old female enrollee has requested reimbursement for inpatient mental health services provided from 11/7/17 to 12/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder and depression. The physician reviewer found that applying the level of care utilization system (LOCUS) criteria, the inpatient mental health services provided from 11/7/17 to 12/6/17 were not medically necessary for treatment of this patients behavioral health issues. The patient presented with significant risk of harm (score 3) with a history of a suicide attempt at age 15 by attempting to overdose on Advil. The patient also has a history of self-cutting from the ages of 14-19 years old. On 11/7/17 and several days prior, the patient had intermittent passive suicidal thoughts. The patient demonstrated moderate functional impairment (score 3) and due to her symptoms, the patient was unable to fulfill her responsibilities in her work. The patient showed significant co-morbidity (score 3) with history of bipolar II, cluster B traits, and bingeing, purging, and restricting behaviors. The patient did not have substance abuse problems. The patients recovery environment is mildly stressful (score 2) as she demonstrated distress while she was traveling in Paris due to isolation. The patients recovery environment was supportive (score 2) and she demonstrated moderate response to prior treatment (score 3). The patient demonstrated positive engagement and recovery (score 2) as she was described as attentive and engaged during treatment. The patient had a positive attitude toward recovery and treatment. These findings give the patient a composite score of 18, which is consistent with intensive outpatient program (IOP) level of care. The patient continued to require treatment for her of bipolar II, cluster B traits, and bingeing, purging, and restricting behaviors, but this could have been safely and effectively provided in a less restrictive environment. Therefore, the services at issue were not medically necessary. Based on the foregoing discussion, 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: The patient is a 28-year-old transgender female who is seeking facial feminization surgery.  The Health Insurer has denied coverage for facial feminization surgery. Per the Health Insurer, the requested services are not medically necessary for the treatment of this patient.

Context:
Summary Reviewer

The patient is a 28-year-old transgender female who is seeking facial feminization surgery.  The Health Insurer has denied coverage for facial feminization surgery. Per the Health Insurer, the requested services are 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 purpose of medically necessary facial feminization surgery is to relieve gender dysphoria. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. World Professional Association for Transgender Health, Inc. (WPATH) states, Non-genital surgical proceduresnotably facial feminization surgeryare often of greater practical significance in the patients daily life than reconstruction of the genitals. WPATH notes, These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. The current medical evidence supports the requested services in this patients case. Therefore, the requested facial feminization surgery is medically necessary for the treatment of this patient.

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


Answer: A 29-year-old female enrollee has requested reimbursement and prospective authorization and coverage for OxyContin 20 mg three times per day from 2/9/18 forward. The Health Insurer has denied this request indicating that the medication dosage at issue was not and is not medically necessary for treatment of the enrollee who has been assessed with chronic pain syndrome.

Answer: In this case, the patient was recently taking 135 MME per day.

Context:
Summary Reviewer

A 29-year-old female enrollee has requested reimbursement and prospective authorization and coverage for OxyContin 20 mg three times per day from 2/9/18 forward. The Health Insurer has denied this request indicating that the medication dosage at issue was not and is not medically necessary for treatment of the enrollee who has been assessed with chronic pain syndrome. The physician reviewer found that the medical literature states that dose escalation is not a long-term plan but a short-term plan for the treatment of tolerance. In the documentation available for review, there were no objective treatment goals for pain and function noted for the requested medication. In addition, several requirements for opioid prescribing have not been documented to be performed. Therefore, the need to use them as the primary medication treatment strategy for pain has not been established (Chou, et al). The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate release opioids instead of extended release/long-acting (ER/LA) opioids. When opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, and should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or more MME per day or carefully justify a decision to titrate dosage to 90 or more MME per day. In this case, the patient was recently taking 135 MME per day. However, there is no submitted evidence based rationale given by the provider to support the potential long-term consequences with the continual increase in opioids. Risk and benefit analysis must be performed to justify the requested level of 90 MME per day. It is also reasonable to consider alternatives to opioids. Moreover, pure mu agonists are not considered evidence based treatments for fibromyalgia and the adverse effects of opioids in fibromyalgia patients are unknown. In addition, the submitted records do not mention the completion of behavior therapy despite much research to support its use. For all of these reasons, reimbursement and prospective authorization and coverage for OxyContin 20 mg three times per day from 2/9/18 forward has not been demonstrated as medically necessary for treatment of the patients medical condition. Therefore, based on the reasons stated above, the medication dosage at issue was not and is not medically necessary for the treatment of this 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 34-year-old male who has been diagnosed with ulcerative colitis. The patient has requested authorization and coverage for Simponi 100 mg every 21 days. The Health Insurer has denied this request and reported that the requested medication regimen is not medically necessary for the treatment of this patient.

Answer: In this case, the patient has failed the standard dose of Simponi, with symptoms of active disease, and elevated fecal calprotectin.

Context:
Summary Reviewer

The patient is a 34-year-old male who has been diagnosed with ulcerative colitis. The patient has requested authorization and coverage for Simponi 100 mg every 21 days. The Health Insurer has denied this request and reported that the requested medication regimen is not medically necessary for the treatment of this patient.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication regimen. The randomized PURSUIT study showed that Simponi serum concentrations are proportional to dose, and higher Simponi concentration was associated with improved clinical outcomes. Studies have shown that dose escalation can recover response to therapy in a significant fraction of patients. One study showed recovery of response in 71% of ulcerative colitis patients undergoing Simponi dose escalation, and another demonstrated improvement in half of patients (Taxonera and Rodriguez, et al; Taxonera and Iborra, et al). In this case, the patient has failed the standard dose of Simponi, with symptoms of active disease, and elevated fecal calprotectin. Dose escalation can recover response and prevent complications, such as disease flare, hospitalization, toxic megacolon, and dysplasia with risk of colorectal cancer. Therefore, Simponi 100 mg every 21 days is medically necessary for the treatment of this patient.

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


Answer: A 32-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 6/11/17 through 7/2/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues.

Answer: On 5/27/17 admission, the patients symptoms prevented him from functioning properly.

Answer: by 6/11/17, the patient was not an imminent danger to self or others, and he was not gravely disabled. He was performing his activities of daily living independently. He continued to endorse passive suicidal ideation without intent, as well as anxiety and depression. He continued to report auditory and visual hallucinations, which the records suggest are the patients baseline. His psychotic symptoms were stabilized on Clozaril 500 mg, which had been titrated up from 300 mg.

Answer: His other medications were unchanged, and he was compliant. His family and girlfriend provided a safe and supportive environment.

Context:
Summary Reviewer

A 32-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 6/11/17 through 7/2/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that the medical records provided for review do not support the medical necessity of the RTC services provided from 6/11/17 through 7/2/17 for treatment of this patients behavioral health issues. On 5/27/17 admission, the patients symptoms prevented him from functioning properly. However, by 6/11/17, the patient was not an imminent danger to self or others, and he was not gravely disabled. He was performing his activities of daily living independently. He continued to endorse passive suicidal ideation without intent, as well as anxiety and depression. He continued to report auditory and visual hallucinations, which the records suggest are the patients baseline. His psychotic symptoms were stabilized on Clozaril 500 mg, which had been titrated up from 300 mg. Further, Clozaril titration does not require a RTC setting and can be performed in the outpatient setting. His other medications were unchanged, and he was compliant. His family and girlfriend provided a safe and supportive environment. He no longer required 24-hour monitoring in the RTC setting, and could have continued treatment at IOP level of care. Thus, the RTC services provided from 6/11/17 through 7/2/17 were not medically necessary. Based on the foregoing discussion, 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 66-year-old female enrollee has requested authorization and coverage for Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas obstructive sleep apnea.

Answer: The patient has obstructive sleep apnea and has no nasal obstruction. She has not been able to tolerate continuous positive airway pressure therapy.

Context:
Summary Reviewer 1

A 66-year-old female enrollee has requested authorization and coverage for Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas obstructive sleep apnea. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. The patient has obstructive sleep apnea and has no nasal obstruction. She has not been able to tolerate continuous positive airway pressure therapy. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device, given the intolerance to continuous positive airway pressure therapy, anterior posterior collapse, no central apnea, and body mass index and apnea-hypopnea index within FDA criteria. Therefore, Inspire upper airway stimulation system is likely to be more beneficial than any available standard therapy.

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


Answer: A 66-year-old female enrollee has requested authorization and coverage for Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas obstructive sleep apnea.

Answer: She has failed continuous positive airway pressure therapy and is not an optimal candidate for oral appliance therapy due to the severity of her obstructive sleep apnea.

Context:
Summary Reviewer 2

A 66-year-old female enrollee has requested authorization and coverage for Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas obstructive sleep apnea. The physician reviewer found that there is sufficient support for the requested services in this patientas case. She has failed continuous positive airway pressure therapy and is not an optimal candidate for oral appliance therapy due to the severity of her obstructive sleep apnea. The alternative, no treatment, may lead to potential harms, such as increased medical comorbidities, including hypertension, diabetes, congestive heart failure, myocardial infarction, and stroke. There is sufficient evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of obstructive sleep apnea with hypoglossal nerve stimulation or Inspire airway stimulation. Multiple published studies show clinically significant decreases in observed mean apnea-hypopnea index and Epworth Sleepiness Scale scores.  The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy. Therefore, Inspire upper airway stimulation system is likely to be more beneficial than any available standard therapy.

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


Answer: A 41-year-old male enrollee has requested authorization and coverage for CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.

Answer: This patient has gastroesophageal reflux as based on pH recording. However, it appears he has benefited substantially from pantoprazole, and symptoms of gastroesophageal reflux disease recur when he discontinues this drug.

Context:
Summary Reviewer 1

A 41-year-old male enrollee has requested authorization and coverage for CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. The U.S. Food and Drug Administration has approved the LINX device for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux. This patient has gastroesophageal reflux as based on pH recording. However, it appears he has benefited substantially from pantoprazole, and symptoms of gastroesophageal reflux disease recur when he discontinues this drug. As such, he cannot be considered refractory to medical management. Given this patients excellent response and tolerance to conventional acid suppression medication and the attendant surgical risks of LINX implantation, the requested CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure) is not likely to be more beneficial than other available treatment options.

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


Answer: A 55-year-old female enrollee has requested reimbursement for CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition.

Context:
Summary Reviewer 1

A 55-year-old female enrollee has requested reimbursement for CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found the submitted letters from the patient and provider were reviewed.  However, there is a lack of additional pertinent medical documentations, such as progress notes from the ordering provider.  The progress notes submitted are from a different provider which documented the diagnosis of mast cell disorder, chemical sensitivities and food allergy.  The only records from the ordering provider were testing records, which are insufficient to support the services at issue.  The submitted records do not support a covered indication for the services at issue.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: The parent of a 15-year-old male enrollee has requested reimbursement for CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition.

Context:
Summary Reviewer 2

The parent of a 15-year-old male enrollee has requested reimbursement for CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  Allergen immunotherapy is a long-term treatment that decreases symptoms for many people with allergic rhinitis, allergic asthma, conjunctivitis or stinging insect allergy.  Allergy shots decrease sensitivity to allergens and often lead to lasting relief of allergy symptoms even after treatment is stopped.  Indications for allergen immunotherapy include allergic asthma and rhinitis, conjunctivitis, as well as venom-induced anaphylaxis.  In this patients case, the records do not support the services at issue.  Without a diagnosis of asthma, rhinitis, conjunctivitis or anaphylaxis, the services at issue cannot be recommended.  In sum, CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15 were not likely to have been of greater benefit than other treatment options.  Based upon the information set forth above, the services at issue were 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 59-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/10/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition.

Answer: this patient had an early stage melanoma followed by a node positive recurrence. DecisionDx-Melanoma testing was performed on the recurrent tumor.

Context:
Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/10/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma followed by a node positive recurrence. DecisionDx-Melanoma testing was performed on the recurrent tumor. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. The role of DecisionDx-Melanoma testing for recurrent node positive disease has not been established. In sum, DecisionDx-Melanoma testing performed on 5/10/18 was not likely to have been of greater benefit than other methods of evaluating this patient.

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


Answer: A 29-year-old female enrollee has requested reimbursement for the Anser ADA test provided on 10/13/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis.

Context:
Summary Reviewer 2

A 29-year-old female enrollee has requested reimbursement for the Anser ADA test provided on 10/13/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis.  The physician reviewer found that antibodies to adalimumab (ADA) are present in a substantial number of patients treated with adalimumab, and in some patients there may be a correlation between the level of these antibodies and clinical response. However, there are technical factors relating to the use of different assay methods across studies, and it has not yet been established whether the use of threshold level aid in the discrimination of response to adalimumab. There are patients who do not respond to adalimumab (primary non responders), and patients who appear to lose their response to adalimumab over a period of time (secondary non responders). However, some evidence suggests that low serum drug levels and/or the presence of drug antibodies to may play a role in primary or secondary response failures. Menting and colleagues noted that patients with no ADA formation in the first 24 weeks of treatment have little chance of it in the following 24 weeks. The presence of ADA is strongly correlated with adalimumab concentration. Standard alternatives to Anser ADA testing, in patients like this patient, include shortening the interval between doses, increasing the dose, or switching to a different agent. At this time, the peer-reviewed medical literature does not support the use of the Anser ADA test as performed on 10/13/14 as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 58-year-old female enrollee has requested authorization and coverage for Ibrance 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees breast cancer.

Context:
Summary Reviewer 2

A 58-year-old female enrollee has requested authorization and coverage for Ibrance 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees breast cancer.  The physician reviewer found that Turner and colleagues reported that treatment with Ibrance and Faslodex is approved for ER positive metastatic disease. The authors reported that among patients with hormone receptor positive metastatic breast cancer who had progression of disease during prior endocrine therapy, Ibrance combined with Faslodex resulted in longer progression-free survival than Faslodex alone. Given this support, the requested Ibrance 100 mg is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: The parent of a five-year-old female enrollee has requested authorization and coverage for genetic testing. The Health Insurer has denied this request indicating that the requested testing is not medically necessary for evaluation of the enrollees developmental delay.

Context:
Summary Reviewer

The parent of a five-year-old female enrollee has requested authorization and coverage for genetic testing. The Health Insurer has denied this request indicating that the requested testing is not medically necessary for evaluation of the enrollees developmental delay. The physician reviewer found that based on the medical literature and the presented clinical records submitted for review, the request for genetic testing is medically necessary for evaluation of the patients medical condition. The clinical utility of CMA is well established in the peer-reviewed literature and is considered a first-line genetic test for patients with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics (AAP), the American College of Medical Genetics (ACMG), the American College of Neurology (AAN) and the Child Neurology Society (CNS) (Schaefer, et al; Moeschler, et al; Shevell, et al; Shen, et al). CMA technology has been shown to provide clinically actionable information. The study by Coulter and colleagues demonstrated that CMA results influenced medical care by in the majority of patients by precipitating medical referrals, diagnostic imaging, and specific laboratory testing supporting the use of CMA as a clinically useful diagnostic test. Current data suggest that many clinically significant genetic changes can impact neurodevelopment without associated anatomic departures. For the reasons provided, the request for genetic testing has been established as medically necessary for evaluation of the patients medical condition. Therefore, the requested testing is medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.

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


Answer: A 42-year-old female enrollee has requested authorization and coverage for disc fusion. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition.

Answer: this patients

Answer: degenerative disc disease with a 4 mm protrusion at L5-S1

Answer: did not respond to nonoperative treatment.

Context:
Summary Reviewer

A 42-year-old female enrollee has requested authorization and coverage for disc fusion. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Anterior lumbar interbody fusion is associated with higher fusion rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine, including those with instability.  There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone anterior lumbar interbody fusion has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. With regard to the type of interbody spacer used, frozen allograft is associated with lower pseudarthrosis rates compared with freeze-dried allograft. Based on these guidelines, the requested anterior lumbar interbody fusion procedure is likely to be beneficial for this patients severely symptomatic degenerative disc disease with a 4 mm protrusion at L5-S1 that did not respond to nonoperative treatment. Therefore, the requested 63077, 22558 and 22845 are medically necessary for the treatment of this patient.

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


Answer: The patient is an 11-year-old female with short stature. The patientas parent has requested authorization and coverage for Nutropin AQ Nuspin. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient.

Answer: This patient was growing along the 5th percentile from age 4 years and was subsequently started on growth hormone therapy. She has a good IGF-1 generation on growth hormone treatment. This patient exhibited signs of growth failure before the growth hormone treatment was started. Per the submitted documentation, she had a good response to growth hormone therapy in terms of growth velocity.

Context:
Summary Reviewer

The patient is an 11-year-old female with short stature. The patientas parent has requested authorization and coverage for Nutropin AQ Nuspin. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. This patient was growing along the 5th percentile from age 4 years and was subsequently started on growth hormone therapy. She has a good IGF-1 generation on growth hormone treatment. This patient exhibited signs of growth failure before the growth hormone treatment was started. Per the submitted documentation, she had a good response to growth hormone therapy in terms of growth velocity. Continuation of growth hormone therapy is medically appropriate in this case. Therefore, Nutropin AQ Nuspin is medically necessary for the treatment of this patient.

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


Answer: A 26-year-old female enrollee has requested reimbursement for laboratory services (CPT code 83993) performed on 10/5/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees structuring ileocolic Crohns disease.

Context:
Summary Reviewer 2

A 26-year-old female enrollee has requested reimbursement for laboratory services (CPT code 83993) performed on 10/5/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees structuring ileocolic Crohns disease. The physician reviewer found that fecal calprotectin, elaborated by neutrophils, is elevated when there is inflammation within the lumen of the gastrointestinal tract. In the setting of post-operative Crohns, a progressive rise is usually indicative of disease recurrence. Following serial measurements is a reasonably strategy rather than subjecting the patient to serial colonoscopy exams to assess disease activity. Performance of serial post-operative fecal calprotectin levels can be considered a standard of care strategy. Accordingly, the laboratory services (CPT code 83993) performed on 10/5/17 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

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


Answer: A 46-year-old female enrollee has requested reimbursement for CPT code 84999 performed on 1/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma.

Context:
Summary Reviewer 3

A 46-year-old female enrollee has requested reimbursement for CPT code 84999 performed on 1/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, CPT code 84999 performed on 1/12/17 was not likely to have been more efficacious than other available methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 37-year-old female enrollee has requested authorization and coverage for lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition.

Context:
Summary Reviewer 1

A 37-year-old female enrollee has requested authorization and coverage for lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the proposed procedure has been studied for over a decade, and the peer-reviewed literature supports the benefit of the procedure. Scaglioni and colleagues performed a systematic review of lymphovenous anastomosis for the treatment of lymphedema. The authors noted, aAlthough the studies included in this review showed great heterogeneity, lymphovenous anastomosis surgery revealed both objective and subjective improvements in most patients.a Thomas and colleagues noted, aThe findings suggest that the real impact of living with lymphedema is much more challenging than previously identified. The findings suggest that lymphovenous anastomosis can give a future of greater choice for some of its recipients, but further research should explore longer-term benefits. Lymphovenous anastomosis could offer hope to some people with lymphedema, but a realistic expectation is essential.a There is sufficient support for the requested services in this clinical setting. Therefore, lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping is likely to be more beneficial than other available standard therapy.

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


Answer: A 42-year-old female enrollee has requested authorization and coverage for destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition.

Answer: In this case, the patient has had a history of chronic low back pain that has persisted for several years, which has been refractory to multiple modes of standard care.

Context:
Summary Reviewer 3

A 42-year-old female enrollee has requested authorization and coverage for destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that Fischgrund and colleagues performed a randomized controlled trial regarding the two-year clinical outcomes for chronic low back pain patients treated with radiofrequency ablation of the basivertebral nerve. The authors noted, aBasivertebral nerve ablation appears to be a safe, durable, minimally invasive treatment for the relief of chronic low back pain in a patient population that typically has few effective treatment options.a Lorio and colleagues concluded, aThe procedure is supported by level 1 evidence including two randomized controlled trials demonstrating a statistically significant decrease in pain and an improvement in function with outcomes sustained to at least 24 months in a limited number of studies.a In this case, the patient has had a history of chronic low back pain that has persisted for several years, which has been refractory to multiple modes of standard care. Based on the available medical records for review and the current studies, the requested services are likely to be superior over other treatment options. Thus, destruction of intraosseous basivertebral nerve is likely to be more beneficial than any available standard therapy.

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