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Persius 1

Summary Reviewer A 52-year-old male enrollee has requested reimbursement for acute hospital admission at telemetry level of care provided from 2/13/18 through 2/14/18. 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. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had known coronary disease and presented with atypical (at rest) chest pain without any objective evidence of coronary ischemia or hemodynamic instability. In this circumstance, it would have been reasonable to anticipate a hospital length of stay less than two midnights, and it would have been safe to manage the patient at an observational level of care as opposed to a hospital admission. After the initial evaluation, it was not likely that the patient had an acute coronary syndrome based on the above findings. Thus, acute hospital admission at telemetry level of care provided from 2/13/18 through 2/14/18 was 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

31dc5f0e9b9086cd2f88cc6e24ec0ce9

./data/processed/ca_cdi/summaries/19-6643.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer The parent of a 13-year-old male enrollee has requested authorization and coverage for Cimzia loading dose 400 mg (two injections), then 200 mg subcutaneous every two weeks, three applications. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who has been diagnosed with inflammatory bowel disease, psoriasis and juvenile ankylosing spondylitis. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this clinical setting. Cimzia is an anti-tumor necrosis factor medication which is indicated for the treatment of psoriasis, inflammatory bowel disease and ankylosing spondylitis/sacroiliitis. These diseases are the same in children and adults and respond to therapy similarly. Currently, there is an active trial being conducted, the Pediatric Arthritis Study of Certolizumab Pegol (PASCAL). This is a phase 3, multicenter, open-label study to assess the pharmacokinetics, safety, and efficacy of certolizumab pegol (Cimzia) in children and adolescents with moderately to severely active polyarticular-course juvenile idiopathic arthritis. In this patients case, Cimzia is a medically appropriate treatment option. Thus, Cimzia loading dose 400 mg (two injections), then 200 mg subcutaneous every two weeks, three applications are medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

06002a2af7439e455a8fb4f1390c74ac

./data/processed/ca_cdi/summaries/19-6588.jsonl

Insurer Denial Overturned

Medical Necessity

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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

3efe90bb395de1f16001ce6bffd95dab

./data/processed/ca_cdi/summaries/16-4374.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 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 current medical evidence does not support the services at issue in this clinical setting. The patient is being treated with subcutaneous immunotherapy for mast cell disease, food allergy and multiple chemical sensitivities. Per the literature, subcutaneous immunotherapy using preparations of aeroallergens may be indicated in specific clinical settings. Studies have demonstrated that patients with both asthma and allergic rhinitis derive particular benefit. In this case, the patient does not have a diagnosis that is appropriate for subcutaneous immunotherapy. Therefore, the superior efficacy of the services at issue has not been established. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

3efe90bb395de1f16001ce6bffd95dab

./data/processed/ca_cdi/summaries/16-4374.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 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 in this case, the patient has a history of mast cell disorder, multiple chemical sensitivities and food allergy. Allergen immunotherapy is a well-standardized treatment options. The current national guidelines indicate that allergen immunotherapy may be efficacious in the treatment of allergic rhinitis, allergic conjunctivitis, allergic asthma, and stinging insect hypersensitivity. In this case, there is no evidence of the above diagnoses. As such, CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15 was not likely to have been more efficacious 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

3efe90bb395de1f16001ce6bffd95dab

./data/processed/ca_cdi/summaries/16-4374.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 1 A year-old female enrollee has requested reimbursement for collagen crosslink testing provided on 4/17/19. 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 Osteoporosis is a condition of thinning of the bones that leads to an increased risk of fracture. It is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults), as measured by dual-energy x-ray absorptiometry (DEXA). Bone mineral density assessment via DEXA is still the criterion standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. Medical evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. There is sufficient support for the services at issue in this clinical setting. Therefore, collagen crosslink testing provided on 4/17/19 was likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

d07f54a12c5a52e81217b225e14c09fa

./data/processed/ca_cdi/summaries/19-6860.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A year-old female enrollee has requested reimbursement for collagen crosslink testing provided on 4/17/19. 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 there is sufficient support for the services at issue in this clinical setting. Bone turnover marker assays measure collagen breakdown products released from osteoclasts and osteoblasts during the process of bone resorption and formation. Bone turnover markers are useful for monitoring osteoporosis treatment. This patient was on bisphosphonate therapy for six years and is currently on a drug holiday. Her provider is monitoring her bone turnover markers so that she can decide the timing of restarting antiresorptive therapy, if needed in the future. The services at issue were medically appropriate in this clinical setting. In sum, collagen crosslink testing provided on 4/17/19 was likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

d07f54a12c5a52e81217b225e14c09fa

./data/processed/ca_cdi/summaries/19-6860.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A year-old female enrollee has requested reimbursement for collagen crosslink testing provided on 4/17/19. 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 the use of bone turnover markers is standard practice among endocrinologists and other specialists in osteoporosis. It is used as a guide to monitor compliance and efficacy of treatment. It also helps to identify non-responders that require additional work-up for other causes of osteoporosis. In this case, the patients provider planned to use the information from this test result to determine whether the patient may resume therapy for osteoporosis and subsequently to monitor therapy. Naylor and colleagues noted that measurement of bone turnover markers after withdrawal of bisphosphonates is potentially useful to evaluate patients that are taking a pause from treatment. Thus, collagen crosslink testing provided on 4/17/19 was likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

d07f54a12c5a52e81217b225e14c09fa

./data/processed/ca_cdi/summaries/19-6860.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer The patient is a 23-year-old female with no formal psychiatric history. The patient has requested reimbursement for inpatient hospitalization care from 4/13/21 through 4/21/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient met the criteria for inpatient services provided from 4/13/21 through 4/21/21. Dimension 1 (risk of harm) assesses potential for harm to self or others. On presentation to the emergency department, the patient was very disorganized but did endorse suicidality. Additionally, the patient was paranoid, wandering outside the home, vigilant to possible threats and compromising her own safety with lack of awareness of the environment. The records support a score of 4 for this dimension. Dimension 2 (function) assesses the degree to which a person is able to fulfill social responsibilities, interact with, maintain physical functioning and capacity for self-care. In this case, the patient was repeatedly agitated on the inpatient unit, requiring medication. She was unable to tolerate social interactions or groups and neglected activities of daily living. The patient was unable to be managed at home without being monitored around the clock, even on discharge from the unit. Thus, the records support a score of 5 for this dimension. Dimension 3 (comorbidity) assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The patient had iron deficiency anemia and numerous abnormalities rheumatologically and neurologically that needed to be pursued through further testing and neuroimaging, although the patient was too paranoid to cooperate for an MRI. Thus, the records support a score of 4 for this dimension. Dimension 4A (recovery environment a stress) assesses the stressors in the environment, social circumstances, and interpersonal relationships. Prior to her admission, the patient perceived significant overwhelming demands in her job that she was unable to meet, prompting her to quit her job but then decompensating further. Thus, the records support a score of 4 for this dimension. Dimension 4B (recovery environment dimension a support) assesses the presence of family and social support to augment the recovery environment. Although the patientas parents are supportive, the patient was so ill that she was unable to access resources from her parents, and the parents were no longer able to keep her safe outside the hospital. Thus, the records support a score of 4 for this dimension. Dimension 5 (treatment and recovery history) assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. Despite full and adequate trial of Risperdal in the hospital, patient continued to be disorganized and paranoid. She had no prior psychiatric history before this admission. Thus, the records support a score of 5 for this dimension. Dimension 6 (engagement) assesses a patientas understanding of their illness and treatment, and ability and willingness to engage in the treatment process. In this case, the patientas paranoid ideation and persecutory delusions prevented her from engaging in groups and milieu therapy in the hospital. She had great difficulty actively engaging in recovery due to her symptoms and disorganization. Thus, the records support a score of 5 for this dimension. These findings give the patient a composite score of 31, which is consistent with medically managed residence-based services or inpatient level of care. Per LOCUS, the patientas scores of 4 for risk of harm and 5 for functional status also support treatment at Level 6 medically managed residence-based services level of care. For these reasons, the inpatient psychiatric admission was medically necessary. Therefore, inpatient hospitalization care from 4/13/21 through 4/21/21 was medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

77317f308978cba499eb7e54b942ea0e

./data/processed/ca_cdi/summaries/21-7312.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer A 62-year-old female enrollee has requested reimbursement for acute hospital admission to telemetry level of care from 9/24/18 through 9/25/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who had a history of chest pain. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records document some coronary risk, chest pain concerning for possible ischemia, a normal cardiovascular physical examination, an unchanged electrocardiogram and an initial negative evaluation in the emergency department. In this circumstance, it would have been reasonable to anticipate a hospital length of stay to require less than 48 hours or less than two midnights, and it would have been safe to manage the patient at an observational level of care as opposed to an inpatient admission. There was no documented hemodynamic instability or objective evidence of coronary ischemia or other acute medical condition to warrant an inpatient admission. Thus, acute hospital admission to telemetry level of care from 9/24/18 through 9/25/18 was 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

7052a5bdf328f5ab046f02509b410751

./data/processed/ca_cdi/summaries/19-6604.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer A 46-year-old male enrollee has requested authorization and coverage for Vemlidy 25 mg daily. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects, such as osteopenia and renal disease. As hepatitis B is chronic in this case, with the possibility of increased disease activity when treatment is discontinued, the request for 12 months of treatment is appropriate. Therefore, Vemlidy 25 mg daily is medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

cbf12aec7f550c6c884e1e9d8a696ad1

./data/processed/ca_cdi/summaries/19-6764.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer The patient is a 20-year-old female who has a history of alopecia totalis. The patient has requested authorization and coverage for Xeljanz (tofacitinib citrate tablet 5 mg). 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. Standard of care for the treatment of alopecia totalis/universalis includes systemic steroids, methotrexate, cyclosporine, Janus kinase inhibition, and contact sensitization with diphenylcylopropenone or squaric acid. Few treatment methods have been evaluated by randomized controlled trials to determine the most efficacious modalities to treat alopecia areata. Therefore, it is challenging for clinicians to guide patients regarding the best therapeutic options. Janus kinase inhibitors, like Xeljanz, do show excellent promise and some great results in treating extensive alopecia. This patient has already had a trial of Xeljanz, is tolerating it well, and is achieving a reduction in her SALT score. Janus kinase inhibition has been found to be well tolerated and effective in the treatment of alopecia. Therefore, Xeljanz (tofacitinib citrate tablet 5 mg) is medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

b5e4d9888316b6e893ddca5d13e5ef3a

./data/processed/ca_cdi/summaries/21-7347.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer A year-old male enrollee has requested reimbursement for inpatient hospital stay at telemetry level of care from 8/06/18 through 8/09/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that at the time of presentation to the emergency department, the patient reported leg pain with swelling. He did not complain of chest pain or difficulty breathing, but he was tachycardic and febrile with increased respiratory rate. The laboratory studies were significant for an elevated troponin. Although there was no obvious cardiac ischemia on echocardiogram, the cardiac enzymes were abnormal and the patient was tachycardic. Admission to an acute inpatient level of care with telemetry was medically reasonable from 8/03/18 through 8/05/18. The patient stabilized medically with treatment, including antibiotics and intravenous fluids. There was no evidence of significant electrolyte abnormalities, cardiac ischemia or dysrhythmia as of 8/05/18. Therefore, inpatient hospital stay at telemetry level of care from 8/03/18 through 8/05/18 was medically necessary for the treatment of this patient. The medical records fail to demonstrate the medical necessity of inpatient hospital stay at telemetry level of care from 8/06/18 through 8/09/18.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

362f7f7a72a93b2b1fe718c8a9992278

./data/processed/ca_cdi/summaries/19-6795.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer The patient is a 58-year-old male with a history Wegeneras granulomatosis. The patient has requested authorization and coverage for Hizentra (immune globulin (human) subcutaneous solution preferred syringe 4 gm/20 ml). The physician reviewer found that the patientas clinical history, presentation and laboratory findings, including low level of immunoglobulin G level and poor antibody response to pneumococcal antibody, support the use of immunoglobulin replacement therapy. The current medical evidence supports subcutaneous immunoglobulin therapy in this clinical setting. Therefore, Hizentra (immune globulin (human) subcutaneous solution preferred syringe 4 gm/20 ml) is medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

afb8d718ca058a9e814a1dc70639d09e

./data/processed/ca_cdi/summaries/21-7376.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer The patient is a 58-year-old male with psoriasis. He has requested authorization and coverage for Otezla 30 mg. 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 based on the psoriasis treatment guidelines put forth by the American Academy of Dermatology- National Psoriasis Foundation, patients who have psoriasis affecting between 3 to 10% (defined as moderate) and greater than 10% (defined as severe) of their body surface area are candidates for phototherapy and systemic medical therapy. There are no step therapy guidelines recommended in this context, and the choice of therapy should be made at the discretion of the treating provider, with attention paid to patient comorbidities. Otezla is U.S. Food and Drug Administration (FDA) approved and indicated for treatment of moderate-to-severe psoriasis and has Level A evidence to support its efficacy. Given that the patient has documented evidence of moderate-to-severe disease combined with the fact that there is documented evidence of effectiveness with starter pack samples, it is medically appropriate to continue this therapy. Therefore, Otezla 30 mg is medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

78f50238ba2a8a8c3fb71930e2de789a

./data/processed/ca_cdi/summaries/20-7065.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 1 A 57-year-old male has requested authorization and coverage for cervical artificial disc replacement. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that he submitted documentation fails to demonstrate the superior efficacy of the requested services. Evidence-based medical guidelines and peer-reviewed literature do not support the use of an artificial disc replacement adjacent to a prior (multilevel) anterior cervical discectomy and fusion. This patient presents with intractable discogenic pain and bilateral C4 motor radiculopathy. He is status post C4-C7 fusion in 2011, with onset of adjacent segment disease at C3-4 in 2012. Artificial disc replacement at the adjacent level has been requested for functional motion preservation. However, the use of an artificial disc replacement adjacent to prior cervical fusion is not supported by current literature. There is a lack of long-term, large volume studies to support the requested services. Therefore, the requested cervical artificial disc replacement is not likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

70bc4084bc36324bcca20916c0737567

./data/processed/ca_cdi/summaries/16-4624.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 57-year-old male has requested authorization and coverage for cervical artificial disc replacement. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this patients case. A review of the current literature pertaining to artificial disc replacement adjacent to a fused level indicates results superior to anterior cervical discectomy and fusion. In particular, due to preservation of the motion, adjacent segment disease may be minimized. The current medical evidence supports the recommended cervical artificial disc replacement in this clinical setting. Therefore, the requested cervical artificial disc replacement is likely to be more effective than other treatment alternatives. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

70bc4084bc36324bcca20916c0737567

./data/processed/ca_cdi/summaries/16-4624.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 57-year-old male has requested authorization and coverage for cervical artificial disc replacement. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. This patient has symptoms noted since May 2012 which suggest multilevel nerve root changes which would not necessarily be addressed through a C3-4 discectomy and artificial disc replacement. Complications specific to total disc replacement include implant failure, wear, bone implant failures, iatrogenic deformity, segmental kyphosis, failed kinematics, neurological injury and infection. It is known that the metal to methyl methacrylate bearing surface will be exposed to the wear mechanisms of abrasion, adhesion, fatigue and third body wear. A continuing particulate load of these particles will occur. It is known that there is a universal giant cell reaction and chronic inflammation in response to wear debris. A justification and rationale for total disc arthroplasty is the prevention of adjacent segment disorder through preservation of motion. However, it remains controversial whether or not motion at the replaced intervertebral disc will be maintained over time, and there is evidence that there is a gradual loss of motion by reason of a number of factors. One of the most important of these factors is myositis ossificans, fibrous tissue and bone or an inflammatory response to wear and to the trauma of surgery, which involves the formation of both. Thus, the requested cervical artificial disc replacement is not likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

70bc4084bc36324bcca20916c0737567

./data/processed/ca_cdi/summaries/16-4624.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer The patient is a 66-year-old man with lumbar stenosis. The patient has requested authorization and coverage for lumbar spine surgery (laminectomy, facetectomy and foraminotomy, single vertebral segment). The Health Insurer has denied this request and reported that 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 submitted documentation supports the medical necessity of the requested services. The patient has severe lumbar stenosis with neurogenic claudication. Decompression is well supported by the referenced literature to reduce pain and increase function. The current medical evidence supports the requested services in this patientas case. Therefore, the requested lumbar spine surgery (laminectomy, facetectomy and foraminotomy, single vertebral segment) is medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

34737e685bd8741bca764d69e14ef119

./data/processed/ca_cdi/summaries/21-7410.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer A 19-year-old male enrollee has requested reimbursement for residential treatment services provided from 11/13/14 through 12/22/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found in this patients case, despite pharmacotherapy with antipsychotic and antianxiety agents, the patient was irritable and anxious with poor eye contact, limited insight and a blunted affect. He endorsed somatic delusions of having toxins in his body, which was likely an extension of his assertion that he had an eating disorder. He also complained of chronic headaches and gastrointestinal distress. During the disputed course of treatment, the patient demonstrated signs of clinical improvement and was engaged in active treatment. Regarding the former, the patient was described by nursing as anxious and isolative with ongoing bodily concerns and affective restriction. However, in mid-December 2014, the patient started to appear more positive, more relaxed and more social, which is consistent with the consolidation of treatment gains. In terms of treatment, the patient benefited from milieu, group, individual and family therapies on the unit. His diagnostic assessment, which had included multiple rule outs upon admission, was determined with far greater certainty. The services provided during the disputed timeframe were for active treatment and were reasonably expected to improve his condition and prevent a more serious episode of illness. Thus, residential treatment services provided from 11/13/14 through 12/22/14 were medically indicated for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

fcfcd6abb5e7c509be686e18ccb3cd29

./data/processed/ca_cdi/summaries/16-4332.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer A 62-year-old male enrollee has requested reimbursement for FoundationOne genomic profile tumor biomarker or gene expression testing performed on 3/01/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that atypical meningiomas are not malignant solid tumors. They are associated with a higher risk of recurrence after surgery. Further therapy may include radiation, but not typically systemic therapy. Next generation sequencing, such as with FoundationOne, is used to identify molecular markers for which targeted therapy exists, either in a clinical trial or as standard therapy. This patient would not be considered for systemic therapy based on his diagnosis, and next generation sequencing would be of limited utility in this case. Therefore, FoundationOne genomic profile tumor biomarker or gene expression testing performed on 3/01/18 was not medically necessary for the evaluation of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

2561cdf64467fe1a95d414f7dff24d28

./data/processed/ca_cdi/summaries/19-6717.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer A 59-year-old male enrollee has requested authorization and coverage for spinal cord stimulator. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the requested device in this clinical setting. Wong and colleagues concluded that the option of spinal cord stimulation should be considered after conservative therapy has failed. They pointed to large randomized control studies which showed that high frequency forms of stimulation was effective for chronic low back pain. A systematic review and meta-analysis by Taylor and colleagues concluded that spinal cord stimulation is an effective pain relieving treatment for chronic low back and leg pain with or without a prior history of back surgery. The mean level of pain relief across 74 studies was found to be 58% at an average follow-up of 24 months. All told, the requested spinal cord stimulator is medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

cdab08d7b1e0c7dfc18d780143cd5728

./data/processed/ca_cdi/summaries/19-6878.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer A 60-year-old male enrollee has requested reimbursement for residential treatment center services provided from 5/30/16 through 6/30/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer that the residential treatment center services provided from 5/30/16 through 6/30/16 were not medically necessary for treatment of the patients medical condition. On admission the patient was not in withdrawals. There was no evidence of post-acute withdrawal symptoms. He was not a danger to self or others. Both his medical and psychiatric conditions could have been treated on an outpatient basis. He was not psychotic or manic. There were no emotional, behavioral, cognitive, or impulsive symptoms to justify residential level of care. He presented for admission with ambivalence, and while in treatment developed a responsible drinking plan. The goal of treatment is abstinence with ongoing vigilance to prevent relapse. In this case, the patient could have been treated at a lower level of care such as intensive outpatient program (IOP) or outpatient with a concurrent 12-step program, and continuation with his psychotherapist. As such, the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

f39fa55ffb61b5b152028316f6919f2c

./data/processed/ca_cdi/summaries/18-6183.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 The parent of a four-year-old male enrollee has requested reimbursement for comparative genomic hybridization performed on 1/19/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found Array-based comparative genomic hybridization has become standard of care to investigate children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies. Until recently, it was a diagnostic test that was employed when the first-line investigation of karyotype returned normal. Over the last eight years, it has emerged as a first-line investigation. This test has become an important and mainstream tool in the practice of clinical genetics. Data have now emerged showing that actionable findings from chromosomal microarray justify its use. All told, comparative genomic hybridization performed on 1/19/15 was likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

50e1e396d714dabccb6287227eca8863

./data/processed/ca_cdi/summaries/16-4380.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 The parent of a four-year-old male enrollee has requested reimbursement for comparative genomic hybridization performed on 1/19/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found the current medical evidence supports the services at issue in this clinical setting. The use of chromosomal microarray testing now plays a central role in the evaluation and diagnosis of children with global developmental delay, cognitive delay, and autism spectrum disorders. Shen and colleagues noted that chromosomal microarray analysis had the highest detection rate among clinically available genetic tests for patients with ASD. Interpretation of microarray data is complicated by the presence of both novel and recurrent copy-number variants of unknown significance. The authors reported that chromosomal microarray testing should be considered as part of the initial diagnostic evaluation of patients with ASD. Based on the literature and current standard of practice, comparative genomic hybridization was likely to have been more beneficial than any other available evaluations. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

50e1e396d714dabccb6287227eca8863

./data/processed/ca_cdi/summaries/16-4380.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 The parent of a four-year-old male enrollee has requested reimbursement for comparative genomic hybridization performed on 1/19/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case. Chromosome microarray testing has been accepted as an appropriate first-line genetic testing for patients with autism spectrum disorders. The testing has the potential to impact treatment, as this may allow the provider to better understand why the patient has certain medical issues. Management also deals with psychological, family, and educational needs, and may vary drastically depending on what is causing a patients issue. Therefore, comparative genomic hybridization performed on 1/19/15 was likely to have been of greater benefit than other modalities. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

50e1e396d714dabccb6287227eca8863

./data/processed/ca_cdi/summaries/16-4380.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer The parent of a 10-year-old male enrollee has requested reimbursement for neuropsychological testing provided on 9/6/16, 9/8/16, 9/16/16, and 9/29/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees cognitive abilities The physician reviewer found that there is a lack of support in the medical literature for the services at issue in this clinical setting. The American Academy of Pediatrics (AAP) recommend obtaining information from the teachers and parents of the student as part of the evaluation for ADHD. The evaluation should also include the Diagnostic and Statistical Manual of Mental Disorders criteria for ADHD. The documentation provided does not indicate that these recommended assessments were performed in this case. Assessment systems such as the Vanderbilt, Connors or the Behavior Assessment System for Children (BASC), are also recommended evaluation tests for ADHD. There is a lack of medical evidence to support neuropsychological testing in this clinical setting. The primary concern, in this patients case was academic functioning and possible ADHD. As such, the services at issue are not supported by the medical literature. Therefore, the neuropsychological testing provided on 9/6/16, 9/8/16, 9/16/16, and 9/29/16 were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

a33ecfc8cce0412500292db5efe83e01

./data/processed/ca_cdi/summaries/17-4851.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer The patient is a 20-year-old female with thyroid cancer. She underwent a total thyroidectomy with lymph node dissection on 5/31/19. The physician reviewer found that the postoperative management and concerns for total thyroidectomy patients, especially those that undergo lymph node dissections, is fairly well understood with algorithms described by major endocrine societies. One of the concerns is hypocalcemia, which can be risk classified based on laboratory values and symptoms. This patients calcium level on postoperative day one was 7.1 mg/dL. This is very low and would qualify as a high risk or a concerning laboratory value. Thus, it was reasonable to continue hospital care, recheck laboratory values and provide calcium supplementation. However, additional submitted records do not substantiate a second night of hospital admission. The patient was seen by the surgeon on 6/01/19 and was found to have no neurologic issues. She was not given calcium supplementation. There were also no concerns documented in the nursing notes. Since the patient was not given calcium, there is no obvious justification for further prolongation of the hospital stay. She could have received pain medication and had follow-up laboratory testing as an outpatient. The initial night of observation and symptom monitoring was medically indicated, but the patient could have been safely discharged on 6/01/19. Therefore, inpatient stay from 5/31/19 through 6/01/19 was medically necessary.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

57e0cd267805ce2e0ec824809e866179

./data/processed/ca_cdi/summaries/20-7051.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer The patient is a 63-year-old female with psoriasis predominantly on her hands/feet-palmoplantar variety. She has requested authorization and coverage for Otezla. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. Based on the psoriasis treatment guidelines put forth by the American Academy of Dermatology-National Psoriasis Foundation, patients who have psoriasis affecting between 3-10% (moderate) and greater than 10% (severe) of their body surface area are candidates for phototherapy and systemic medical therapy. There are no step therapy guidelines recommended in this context, and the choice of therapy should be made at the discretion of the treating physician with attention paid to patient comorbidities. Otezla is U.S. Food and Drug Administration (FDA) approved and indicated for treatment of moderate-to-severe psoriasis and has Level A evidence to support its efficacy. Given that the patient has documented evidence of moderate-to-severe disease, it would be medically appropriate to pursue this therapy. Therefore, Otezla is medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

a999d296a386a0b3046650dadfcaa924

./data/processed/ca_cdi/summaries/21-7382.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 1 A 51-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 7/13/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the breast tomosynthesis performed on 7/13/15 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two dimensional (2D) and three dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the documentation submitted for review and medical literature cited above, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

5440c227ee29bff75a9a5a71b317abdc

./data/processed/ca_cdi/summaries/16-4503.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 51-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 7/13/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support in the medical literature for the services at issue in this clinical setting. The addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. Moreover, the services in dispute prevented additional magnification views. For the reasons provided, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

5440c227ee29bff75a9a5a71b317abdc

./data/processed/ca_cdi/summaries/16-4503.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 51-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 7/13/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. In this case, the patient presented with heterogeneously dense breast tissue. The ability to separate out superimposed tissue enables the possible delineation of an occult mass. In addition, the presence of asymmetry is also an indication for tomosynthesis. For this patient, tomosynthesis was utilized as a problem solving tool. Therefore, the breast tomosynthesis performed on 7/13/15 were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

5440c227ee29bff75a9a5a71b317abdc

./data/processed/ca_cdi/summaries/16-4503.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer The patient is a 35-year-old male with a lengthy history of mood/psychotic episodes and amphetamine use disorder. He was admitted to the residential treatment center due to symptoms of hallucinations, thought disorganization, racing thoughts, and pressured speech. 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. In terms of risk of harm, the records support a score of 3, due to the evidence of self-neglect and inability to care for himself even in the structured residential treatment center environment due to his manic symptoms. He had a history of dangerous actions due to his manic symptoms. With regard to functional status, the records support a score of 4. This patient has been unable to complete community college courses or hold a job for longer than one month. In terms of comorbidity, the records support a score of 4 due to the presence of disabling psychiatric symptoms that interact with and impair his ability to recover from his substance use disorders. With regard to level of stress of the recovery, the records support a score of 4. He is technically homeless but mandated by probation to live in a recovery house. He has historically been unable to remain in recovery houses longer than days to weeks due to relapse of manic and psychotic symptoms. In terms of level of support of the recovery environment, the records support a score of 3. His only natural supports would be his parents, and the patient does not reliably include them. He has not had cohesive professional supports outside of the residential treatment center. With regard to acceptance and engagement, the records support a score of 4. He has had significant treatment exposure but has been unable to achieve complete remission of optimal control of symptoms even with repeated exposure. Attempts to maintain gains attained in intensive treatment have had limited success. Therefore, the patient has a composite score of 22. In this case, the patients functional status and comorbidity were both scored as 4, which would support the residential treatment center placement. Thus, psychiatric residential center treatment provided from 12/30/19 through 1/17/20 was medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

a396ea9621c5fcb3350a69ff7e60d780

./data/processed/ca_cdi/summaries/20-7041.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer The parent of an 11-year-old female enrollee has requested authorization and coverage for Nutropin growth hormone (GH) therapy. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature and ulcerative colitis. The physician reviewer found that according to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than two SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets most of these criteria. The patients pre-treatment height was more than two SDs below the mean for age and gender. In addition, her pre-treatment growth velocity was poor and all other causes of short stature were ruled out. The patients inflammatory bowel disease has been stable and she was not receiving any steroid treatment. All told, her adult predicted height of 56-59 inches supports treatment with GH therapy based on current U.S. Food and Drug Administration (FDA) standards for treatment of idiopathic short stature. Thus, the requested Nutropin GH therapy is medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

415f3f16d2c11e5514a9f8486823a0d0

./data/processed/ca_cdi/summaries/19-6589.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer The parent of a 14-year-old female enrollee has requested authorization and coverage for Nutropin AQ. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature. The physician reviewer found the requested medication is not medically necessary for treatment of the patients medical condition. The patient has idiopathic short stature, but she is more than two years post menarche, and she is past the peak of her pubertal growth spurt and her epiphyses are close to being fused. Thus, she is not a candidate for growth hormone therapy to augment height. As such, Nutropin AQ has not been established as medically necessary for treatment of the patients medical condition. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

272a9c527ce1da59d13fe73011699781

./data/processed/ca_cdi/summaries/17-4927.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 19-year-old male enrollee has requested reimbursement for procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the services at issue were antibody tests to specific serum proteins found in some patients with inflammatory bowel disease (IBD). The diagnosis of IBD is based on endoscopic, radiologic and histopathologic criteria. For several years, there has been a search for noninvasive markers that could replace part of this diagnostic process. Antibody markers, including microbial antibodies, autoantibodies and peptide antibodies, have been explored. At present, no single marker with qualities that are satisfactory for the diagnosis and treatment of IBD have been identified. The 2018 American College of Gastroenterology guidelines make the following statement: aSerologic markers of IBD - Routine use of serologic markers of IBD to establish the diagnosis of Crohn's disease is not indicated (

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

3d835f8ef82716f7b5ebb368af4792f7

./data/processed/ca_cdi/summaries/20-7213.jsonl

Insurer Denial Upheld

Experimental

Summary Statement).a Due to the heterogeneous nature of IBD, there has been extensive research directed toward finding immunologic markers that would assist in disease diagnosis. These studies have focused on antibodies to microbial antigens and autoantibodies. Anti-glycan antibodies are more prevalent in Crohnas disease than in ulcerative colitis but have a low sensitivity, making their use in diagnosis less helpful. In summary, antibody testing as performed in this case is not accepted in the diagnostic evaluation of patients with IBD. Endoscopic, histologic, and radiologic data assist in making the diagnosis and assessing severity. Therefore, procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20 were not likely to have been more beneficial than other available standard therapy.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

3d835f8ef82716f7b5ebb368af4792f7

./data/processed/ca_cdi/summaries/20-7213.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 19-year-old male enrollee has requested reimbursement for procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that Inflammatory bowel disease (IBD) is a heterogeneous group of chronic inflammatory disorders of the gastrointestinal tract with two main distinguishable entities, Crohnas disease (CD) and ulcerative colitis (UC). IBD-unclassified (IBD-U) is a diagnosis that covers the agreya zone of diagnostic uncertainty between UC and CD. Current diagnosis of IBD relies on the clinical, endoscopic, radiological, histological and biochemical features, but this approach has shortcomings, especially in cases of overlapping symptoms of CD and UC. The need for a diagnostic tool that would improve the conventional methods in IBD diagnosis directed the search towards potential immunological markers, since an aberrant immune response against microbial or endogenous antigens in a genetically susceptible host seems to be implicated in IBD pathogenesis. The spectrum of antibodies to different microbial antigens and autoantibodies associated with IBD is rapidly expanding. However, in this patientas case, where a prior diagnosis of left-sided ulcerative colitis has already been rendered, the provideras reliance on marker testing as the final arbiter as to whether patient instead has CD is not standard of care and is not indicated in lieu of gold standard colonoscopy with biopsies. Therefore, procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20 were not likely to have been more beneficial than other available standard therapy.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

3d835f8ef82716f7b5ebb368af4792f7

./data/processed/ca_cdi/summaries/20-7213.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 19-year-old male enrollee has requested reimbursement for procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient had symptoms concerning for inflammatory bowel disease, and has a diagnosis of ulcerative colitis. He was taking azathioprine, a therapy with significant potential adverse effects, and biologic therapy, which has serious potential adverse effects, was being contemplated. Therefore, definitive diagnosis of inflammatory bowel disease was necessary in this case. However, the American Gastroenterological Association guidelines and the American College of Gastroenterology guidelines for ulcerative colitis do not recommend the use of anti-Saccharomyces cerevisiae antibody (ASCA, CPT 86671) and anti-neutrophil cytoplasmic antibody (ANCA, CPT 86021) testing, or any other antibody testing, for diagnosis or management of ulcerative colitis. The American College of Gastroenterology guidelines specifically state that apooled sensitivity of antibody testing for diagnosis of ulcerative colitis is low, and such markers are not used for establishing or ruling out a diagnosis of ulcerative colitis.a American College of Gastroenterology guidelines for Crohnas disease do not recommend the tests either. Therefore, procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20 were not likely to have been more beneficial than other available standard therapy.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

3d835f8ef82716f7b5ebb368af4792f7

./data/processed/ca_cdi/summaries/20-7213.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 1 A 71-year-old male enrollee has requested reimbursement for CPT 29999 performed on 8/27/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. This patient had continued anterior pain and pain with hip flexion after total hip arthroplasty. He had exhausted conservative care, and his provider recommended iliopsoas tendon lengthening. The procedure performed is a well-accepted surgical treatment for iliopsoas tendinitis after total hip arthroplasty in select patients. This patient had trialed medication and activity modification prior to surgery. The surgery performed was likely to have been more beneficial than any available standard treatment. The only available standard treatment is open lengthening, which is a highly invasive intrapelvic procedure. Therefore, CPT code 29999 (left hip iliopsoas lengthening and left hip subspinal decompression) performed on 8/27/18 was likely to have been superior over other treatment options.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

09b5cedda18de8ddaaab1673cb609316

./data/processed/ca_cdi/summaries/19-6797.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 71-year-old male enrollee has requested reimbursement for CPT 29999 performed on 8/27/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presented with persistent and function-limiting left hip pain following total hip arthroplasty in 2015. His pain interfered with activities of daily living. Clinical examination findings were consistent with iliopsoas tendonitis. He had failed long-term conservative treatment, including physical therapy, activity modification and medications. He underwent left hip arthroscopic surgery on 8/27/18 and was diagnosed with left hip iliopsoas tendinitis and anterior inferior iliac spine (AIIS) impingement. Surgery was performed to include left hip aspiration of synovial fluid for culture and sensitivity, left hip lysis of adhesions, iliopsoas lengthening, subspinal decompression, removal of ossified capsule, and left hip parallel capsulotomy and capsular closure. The current medical literature supports iliopsoas lengthening and subspinal decompression following failure of conservative treatment and prior to revision total hip arthroplasty. In sum, CPT code 29999 (left hip iliopsoas lengthening and left hip subspinal decompression) performed on 8/27/18 was likely to have been of greater benefit than other treatment options.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

09b5cedda18de8ddaaab1673cb609316

./data/processed/ca_cdi/summaries/19-6797.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 71-year-old male enrollee has requested reimbursement for CPT 29999 performed on 8/27/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that per the literature, impingement between the acetabular component and the iliopsoas tendon can cause anterior groin pain after total hip replacement. Treatment of the impingement can be nonoperative, arthroscopic, or open, with revision of the acetabular component. In the study by Filanti and colleagues, 35 patients with groin pain after total hip arthroplasty underwent preoperative evaluation, including injection of local anesthetic into the iliopsoas tendon sheath. An extensive arthroscopic debridement was performed. When there were signs of iliopsoas impingement, a transcapsular tenotomy was performed according to the Wettstein technique. The authors concluded that hip arthroscopy in treatment of anterior iliopsoas impingement is useful, more so than the open technique. Guicherd and colleagues noted that the procedure relieved pain in 92 percent of patients. Thus, CPT code 29999 (left hip iliopsoas lengthening and left hip subspinal decompression) performed on 8/27/18 was likely to have been more efficacious than other treatment options.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

09b5cedda18de8ddaaab1673cb609316

./data/processed/ca_cdi/summaries/19-6797.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer A 54-year-old male enrollee has requested reimbursement for inpatient mental health services provided from 1/26/16 through 3/24/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. He was not a danger to himself or others. He was not delusional or paranoid, and had no hallucinations. The patient remained depressed, but he showed overall slow and incremental improvements in hygiene, appetite and fluid intake, participation in on and off unit groups, and communication/interaction with others. He was cooperative and medication compliant, and he tolerated medication changes well. Although the patient received a course of electroconvulsive therapy while hospitalized, electroconvulsive therapy is most commonly administered on an outpatient basis and there is no indication that this was needed on an inpatient basis. All told, inpatient mental health services provided from 1/26/16 through 3/24/16 were not medically indicated 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

b7f5604d508b1aa1907ea9fc3cfd0967

./data/processed/ca_cdi/summaries/16-4777.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 48-year-old female enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 4/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found there is sufficient support for the services at issue in this clinical setting. It has been established that adjuvant chemotherapy is of benefit to patients with stage III (node positive) colon cancer. It is much more controversial as to its value in stage II colon cancer, as in this patients case. Most oncologists have made this decision based on specific pathologic features, such as a poorly differentiated histology, lymphovascular invasion, or presentation with obstruction or perforation. Another approach is with the use of genetic panels. The Oncotype DX Colon Cancer Assay is a 12-gene panel that predicts the risk of recurrence of the cancer in both stage II and III colon cancer. This assay appears to predict the risk of recurrence with accuracy beyond what could be predicted from these usual pathologic features. The medical evidence supports the use of Oncotype DX Colon Cancer Assay in assessing the potential value of adjuvant chemotherapy. Therefore, Oncotype DX Colon Cancer Assay performed on 4/28/16 was likely to have been more efficacious 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

758d0aa9981bfc366c1902f9ea90a211

./data/processed/ca_cdi/summaries/16-4712.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 48-year-old female enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 4/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found this patient had stage II colon cancer. Although Oncotype DX Colon Cancer Assay provides prognostic data, to date it does not provide predictive data for the benefit of chemotherapy. Per the medical evidence, the clinical utility of gene expression assays, including the 12-gene recurrence score, is uncertain, and information is lacking regarding the extent to which assay results do or do not classify patients into distinct groups with clinical relevance. National Comprehensive Cancer Network guidelines state that there are insufficient data to recommend the use of multigene assays, such as the Oncotype DX Colon Cancer Assay, to determine adjuvant therapy. In sum, Oncotype DX Colon Cancer Assay performed on 4/28/16 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

758d0aa9981bfc366c1902f9ea90a211

./data/processed/ca_cdi/summaries/16-4712.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 48-year-old female enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 4/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found the medical evidence shows that adjuvant chemotherapy confers a survival advantage for patients with stage III colorectal cancer, but not for those with stage II disease. Meta-analyses have not shown any survival advantage for 5-FU/leucovorin treatment in stage II patients. The reasons for this conclusion are complex. Stage II patients do well after surgery alone, so that the magnitude of the survival benefit conferred by adjuvant chemotherapy is small. Additionally, randomized clinical trials to date have had too few stage II patients to discern a statistically significant advantage. In contrast, the benefit for stage III patients is quite significant, and it is likely that stage II patients benefit as well. Therefore, subset analyses to identify those patients with prognostic features that may predict for chemotherapy benefit have been analyzed. For example, oncologists consider adjuvant treatment for those stage II patients with T4 disease, obstructing lesions, and other biomarkers. The Oncotype DX Colon Cancer Assay uses a reverse transcriptase-polymerase chain reaction assay for 12 genes in an algorithm that can be used to predict recurrence. The medical evidence for the test is sufficient to allow its use to estimate the risk of recurrence for stage II patients when incorporated with other tests, such as standard pathology and microsatellite instability testing. Thus, Oncotype DX Colon Cancer Assay performed on 4/28/16 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

758d0aa9981bfc366c1902f9ea90a211

./data/processed/ca_cdi/summaries/16-4712.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 1 A 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain. The physician reviewer found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The evidence based peer-reviewed literature support SI joint fusion in this clinical setting. Polly and colleagues concluded in their study that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. The authors noted that pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. The International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive SI joint fusion provide specific indications for surgery. The criteria include: significant SI joint pain or significant limitations in activities of daily living because of SI joint pain; SI joint pain confirmed by at least three positive SI joint provocative tests; confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period; failure to respond to at least six months of non-surgical treatment including medications, rest, physical therapy, and SI joint steroid injection or rhizotomy; and, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been clearly considered, investigated and ruled-out. In this case, the patient presents with chronic left hip/buttocks pain with significant functional limitation. Detailed evidence of at least six months of reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Clinical exam findings have documented significant tenderness at the SI joint with six positive SI joint provocative tests. There is radiographic evidence of bilateral joint arthrosis with joint space narrowing. There is no imaging evidence of lumbosacral spine neural compression pathology. Multiple bilateral SI joint injections have produced 90% pain relief. The peer-reviewed supports the requested SI joint fusion as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy in this clinical setting. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

adf766f828238697ea6fd80ccfe84fa9

./data/processed/ca_cdi/summaries/17-4853.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain. The physician reviewer found that the North American Spine Societys recommendations include that percutaneous sacroiliac joint fusion should only be considered when all inclusion criteria have been met. The authors state that due to the relatively moderate evidence, it is particularly critical that inclusion criteria are scrutinized and patient selection is executed with vigilance. In this case the patient meets North American Spine Society criteria for the proposed sacroiliac joint fusion. She has had at least 75 percent reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular SIJ injection on two separate occasions. In addition, the postoperative CT scan on 11/5/15 shows no ongoing neural compression and no central canal or foraminal stenosis on the postoperative CT scan. This patient meets all NASS criteria for the proposed surgery. For these reasons, sacroiliac joint fusion surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

adf766f828238697ea6fd80ccfe84fa9

./data/processed/ca_cdi/summaries/17-4853.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain. The physician reviewer found that Polly and colleagues performed a randomized controlled trial of minimally invasive sacroiliac joint fusion using triangular titanium implants was compared to nonsurgical treatment at 12 months. A total of 148 patients with sacroiliac joint dysfunction were randomly assigned to minimally invasive sacroiliac joint fusion with triangular titanium implants or nonsurgical treatment. The study showed that minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction caused by degenerative sacroiliitis or sacroiliac joint disruptions. Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. In addition, Whang and colleagues compared sacroiliac joint fusion using triangular titanium implants to nonsurgical management. The conclusions were that at six-month follow-up the minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction due to degenerative sacroiliitis or sacroiliac joint disruptions. In this case, physical examination and multiple diagnostic sacroiliac injections have identified the pain generator. Therefore, evidence of neural compression on the imaging studies is not relevant. Based upon a review of the recent literature, the requested minimally invasive sacroiliac joint fusion has been established 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 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

adf766f828238697ea6fd80ccfe84fa9

./data/processed/ca_cdi/summaries/17-4853.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer A 31-year-old female enrollee has requested authorization and coverage for Forteo. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that thesubmitted documentation supports the medical necessity of the requested medication. Osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis. Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates. In humans, the elimination half-life of bisphosphonates is over 10 years. This raises concerns that in women of childbearing age, alendronate stored in the bone may be mobilized during pregnancy and taken up by fetal bones and may be potentially teratogenic. Newer treatment agents have become available over the past few years, including teriparatide (Forteo). Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone. The pharmacokinetics of Forteo have been characterized by rapid absorption and rapid elimination, resulting in a short total duration of exposure to the peptide. Therefore, Forteo (teriparatide) is medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

391ae5e2f2d8d37aa572da32d998ad84

./data/processed/ca_cdi/summaries/19-6634.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer A 50-year-old male enrollee has requested authorization and coverage for Vemlidy. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B. A review of the record indicates the enrollee has a history of hepatitis B. On 5/9/17, the enrollee was noted to have hepatitis B complicated by cirrhosis. The record indicates the enrollee has been treated with Viread 300 mg daily. At that time, the provider recommended treatment with Vemlidy which has a better renal and bone safety profile than Viread. The Health Insurer indicates the requested medication is not medically necessary for treatment of the enrollees medical condition. At issue is whether the requested medication is medically necessary for treatment of the enrollees medical condition.I have determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

94ab6546281b96ac16f2747c0ac6c85f

./data/processed/ca_cdi/summaries/18-6178.jsonl

Insurer Denial Overturned

Medical Necessity

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

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

403d07f9e8292cd611503d1eb7b72082

./data/processed/ca_cdi/summaries/15-4138.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 1 A 56-year-old male enrollee has requested authorization and coverage for proton treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees tumor of the hypopharynx. The physician reviewer found that there is limited, evidence based, peer reviewed literature on the effectiveness of proton therapy over other forms of treatment in this clinical setting. A 2014 review article by Holliday and Frank cited only one study (of 29 patients) of proton therapy for oropharyngeal cancer, and none are cited for hypopharyngeal cancers. Data on proton therapy for hypopharyngeal cancers are scant. Likewise, there is scant data which compares outcomes with proton therapy versus intensity modulated radiation therapy (IMRT). While preliminary dosimetric data suggests that proton therapy may be better at sparing pharyngeal constrictor muscles spinal cord, parotid glands, larynx, and brainstem whether dose reduction to any of these structures (beyond what IMRT can achieve) results in any benefit in clinical outcome is unknown. There is not enough studies that definitively show that proton therapy (in general) affords benefit over conventional radiation therapy. The most recent National Comprehensive Cancer Network guidelines (v2.2016) do not address proton therapy for pharyngeal cancers and explicitly state that the role of proton therapy is being investigated for ethmoid and maxillary sinus cancers. At this time, further clinical data through prospective clinical trials are needed regarding cases in which the target is the primary volume located near critical structures. For this patient, there is no documentation that IMRT would result in an unacceptable plan. Currently, there are insufficient data to recommend proton treatment for routine head and neck radiation therapy outside of clinical trials. In summary, proton treatment is not likely to be superior to IMRT. Therefore, based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

e83aa06740c759d4758e7df741efc82a

./data/processed/ca_cdi/summaries/17-4866.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 56-year-old male enrollee has requested authorization and coverage for proton treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees tumor of the hypopharynx. The physician reviewer found Currently, that there is a lack of clinical data in the medical literature to indicate the superior efficacy of the requested services when compared to conventional treatment options. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT). A recent comparative analysis by Sio and colleagues found no significant difference in symptom burden in the acute and chronic phases of treatment with proton therapy compared to photon therapy for head and neck cancer. Also, the ASTRO emerging technology committee report on proton therapy specifically states that there is insufficient data to recommend proton beam therapy for routine head and neck radiation therapy outside of clinical trials, (Allen, et al). Moreover, there is a lack of level I evidence to support the use of proton therapy for the treatment of head and neck cancer. The patients previous history of treatment with radioactive iodine does not preclude the use of standard treatment with photons. Therefore, proton therapy is not likely to be more effective than standard therapy in the treatment of this patients medical condition. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

e83aa06740c759d4758e7df741efc82a

./data/processed/ca_cdi/summaries/17-4866.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 56-year-old male enrollee has requested authorization and coverage for proton treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees tumor of the hypopharynx. The physician reviewer found that in this clinical setting, there is a lack of published literature that compares clinical outcomes of proton beam radiotherapy to standard photon techniques. Consensus group guidelines do not support the use of proton therapy in this setting. Currently, proton therapy for head and neck cancer is being evaluated in National Cancer Institute sponsored trials. However, there is currently insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit beyond conventional radiation therapy. As such, proton therapy is not likely to be superior to the standard options available for treatment of this patients medical condition. Therefore, based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

e83aa06740c759d4758e7df741efc82a

./data/processed/ca_cdi/summaries/17-4866.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer A 28-year-old female enrollee has requested reimbursement for the treatment of dry eye performed on 6/02/15 (codes 68761, 83861 and 92285). The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees dry eyes. The physician reviewer found there is sufficient support for the services at issue in this patients case. The patients dry eye syndrome has not responded to the usual medical therapies, including Restasis drops. Her provider previously recommended use of artificial tears, omega-3 fatty acid supplements, lid hygiene twice daily and sleeping with a humidifier. The use of punctum plugs is the next logical therapeutic regimen. All told, treatment of dry eye performed on 6/02/15 was medically indicated for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

236c99b6c2f43a8889206f8c87c5f74f

./data/processed/ca_cdi/summaries/16-4496.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer A 68-year-old female enrollee has requested reimbursement and prospective authorization and coverage for epidural injections from 6/06/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient has extruded disc material as well as a disc protrusion. These structural defects are not going to be altered by epidural steroids. The patient has spinal stenosis, and the medical literature has shown that epidural steroid injections do not alter the course of the underlying pathology. Radcliff and colleagues compared patients with lumbar spinal stenosis who received epidural steroid injections with patients who did not receive epidural injections during the first three months of the study. The authors noted a worse outcome in the steroid treated group. The current medical evidence does not support the services at issue in this clinical setting. All told, epidural injections from 6/06/16 forward were not and are not medically indicated for the treatment of this patient. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

ce101cb904577f8594c8e10dc3e3ca6f

./data/processed/ca_cdi/summaries/16-4678.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 65-year-old male enrollee has requested reimbursement for gene testing provided on 9/26/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or 2, with class 2 melanomas having a significantly higher rate of recurrence than class 1. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients who have undergone sentinel node biopsy. Berger reported on 156 cases, but there was insufficient follow-up to determine the real value of the assay. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, gene testing provided on 9/26/18 was not likely to have been superior over other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

4550225141be0333c69d048711fcd82e

./data/processed/ca_cdi/summaries/19-6688.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 65-year-old male enrollee has requested reimbursement for gene testing provided on 9/26/18. 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. The National Comprehensive Cancer Network guidelines state 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. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. In sum, gene testing provided on 9/26/18 was not likely to have been more effective than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

4550225141be0333c69d048711fcd82e

./data/processed/ca_cdi/summaries/19-6688.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 65-year-old male enrollee has requested reimbursement for gene testing provided on 9/26/18. 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 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, 0.76-1.0 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 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, gene testing provided on 9/26/18 was not likely to have been of greater benefit than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

4550225141be0333c69d048711fcd82e

./data/processed/ca_cdi/summaries/19-6688.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer A 22-year-old male enrollee has requested reimbursement for outpatient behavioral health services provided from 1/01/16 through 1/05/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found THE submitted documentation fails to demonstrate the medical necessity of the services at issue. On 12/22/15, the patients mood was stable, with no anxiety or depression. He was sleeping well and denied cravings. Therapeutically, he was focused on the conflicted relationship between his mother and grandmother. On 1/01/16, the patient was described as insightful and motivated. He was actively participating in his treatment. His urine drug screen was negative. He was medication adherent, which included quetiapine for insomnia. He had good support from his grandmother. In addition to his relapse prevention efforts, the patient was exploring his characterological organization and consolidating the grief from the death of his stepfather. He was addressing long-term issues, but there was no evidence of an acute psychiatric syndrome, poorly controlled addictive illness or concerning environmental circumstances. Further, the medical records did not include several documents critical to the review process, for example a psychiatric evaluation, psychosocial assessment, multidisciplinary treatment plan or interpretative summary. In the absence of said documents, which typically detail the current status and impact of the illness, analyze the burden of relevant psychosocial stressors, review the outcome of prior interventions and articulate the need for the particular placement, the documentation does not establish that the treatment setting in dispute would have been more likely to improve the patients condition, prevent a more serious episode of illness or reduce morbidity than well-orchestrated community-based programming in a sober living environment. All told, outpatient behavioral health services provided from 1/01/16 through 1/05/16 were not medically indicated 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

7e318a107f3a56d918954c6ef1f4eaee

./data/processed/ca_cdi/summaries/16-4747.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 41-year-old male enrollee has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found the request services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although, the LINX reflux management system is U.S. Food and Drug (FDA) approved it has not been demonstrated to be superior to optimal medical therapy or a standard reflux operation in controlled trials. The evidence to date has been derived from open label studies which have used patients as their own controls. In addition, dysphagia is a common adverse side effect of the procedure and can lead to long term dissatisfaction from the patient's perspective. Therefore, the patients request for the LINX device is not 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

c88302ea8033d1880fc0a06725d52d7d

./data/processed/ca_cdi/summaries/16-4361.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 41-year-old male enrollee has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found according to Lipham and colleagues, Sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on PPIs, with minimal side effects. Patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. The LINX device is U.S. Food and Drug Administration (FDA) approved for patients diagnosed with GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. In this case, the patient presents with GERD based on pH recording. His GERD has proven refractory to medical management, and thus he is expected to benefit from anti-reflux procedures, specifically the LINX device. In addition, the patient does not have any contraindications such as large hiatal hernia, esophageal dysmotility, Barrett's esophagus or cancer. Therefore, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

c88302ea8033d1880fc0a06725d52d7d

./data/processed/ca_cdi/summaries/16-4361.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 41-year-old male enrollee has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found the LINX device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The LINX device, which is U.S. Food and Drug Administration (FDA) approved, is laparoscopically implanted around the esophagus at the esophagogastric junction to mechanically augment the function of the lower esophageal sphincter (LES) for the treatment of GERD. LINX has shown efficacy up to four years in the reduction of the amount of pathologic esophageal acid exposure (Lipham, et al). A multi-institutional, non-randomized, prospective case series of 100 patients by Ganz and colleagues evaluated patients before and after sphincter augmentation with a magnetic device. The authors found exposure to esophageal acid decreased, reflux symptoms improved, and use of proton-pump inhibitors decreased. Based on the minimal invasive nature of the procedure, documented safety and efficacy data in multiple studies, and FDA approval, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

c88302ea8033d1880fc0a06725d52d7d

./data/processed/ca_cdi/summaries/16-4361.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer A 62-year-old male enrollee has requested reimbursement for long term acute care provided from 10/30/18 through 1/11/19. 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 rehabilitation therapy services can be delivered in a wide variety of settings across the care continuum. Post-acute settings differ in the types of available rehabilitation therapies, intensity of therapy, and the level of medical and nursing support. Long-term acute care hospitals offer physical and occupational therapy, 24-hour skilled nursing care and a clinician available 24 hours per day. The medical providers are able to care for active/ongoing medical conditions requiring a clinician-level care (e.g., ventilator-dependent). The long-term acute care hospital setting is considered when the patients need for nursing and rehabilitative services are such that only an inpatient long-term acute care hospital setting can meet the requirements, and the expected length of stay is greater than 25 days. In this case, the documentation does not support that the patient required complex medical treatment (e.g., multiple and prolonged intravenous therapies; monitoring of significantly medically active conditions requiring clinical assessment six or more times a day; multiple and frequent intervention of at least six or more times a day, like ventilator management, cardiac monitoring, complex wound care for multiple wounds stages 3 and above; and the need for specialized high-tech equipment like cardiac monitors, on-site dialysis, or surgical suites) as of 10/30/18. The patient did not require services at the long-term acute care hospital setting that were not available at the acute care hospital or the skilled nursing facility. The requested treatments were not medically necessary at the long-term acute care hospital level of care from 10/30/18 through 1/10/19. Although the patient required hemodialysis, nutrition via a feeding tube and continued wound care, he was medically stable as of 10/30/18 and could have received services at a lower level of care. Therefore, long-term acute care provided from 10/30/18 through 1/11/19 was not medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

8779a05fcb426e57008dbfe927563354

./data/processed/ca_cdi/summaries/19-6844.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer The patient is a 58-year-old male with chronic hepatitis C virus, genotype 1b. The documentation submitted for review indicates he has early stage disease. Fibrospect II testing on 2/13/14 revealed a Metavir score of F0-F1. The patients provider recommends treatment with Viekira Pak. Thus, the patient is requesting authorization and coverage for Viekira Pak. The Health Insurer has denied the requested medication as not medically necessary. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) recommendations for treating hepatitis C, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Denying treatment for patients with early stage hepatitis C is not supported by the peer-reviewed literature. Thus, the recommendation is not deny patients treatment if they have early stage disease, but to provide treatment to avoid complications from advanced disease, including liver failure and extrahepatic complications. AASLD/IDSA guidelines recommend Viekira Pak, a daily fixed-dose combination of paritaprevir (150 mg)/ritonavir (100 mg)/ombitasvir (25 mg) plus twice-daily dosed dasabuvir (250 mg) for 12 weeks for treatment-naive patients with HCV genotype 1 infection. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

7b805a376432958432250d9d2af5e462

./data/processed/ca_cdi/summaries/15-4107.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer 1 A 38-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 11/11/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that the Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Some evidence exists that low serum levels of IFX and/or the presence of antibodies to IFX may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of IFX or the presence of IFX antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). All told, it has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Accordingly, the Anser IFX testing performed on 11/11/15 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

4f9a2c7802f38acdf47b20f9fb60c60d

./data/processed/ca_cdi/summaries/16-4740.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 38-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 11/11/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that the Anser IFX test was ordered to determine the cause for the patients possible loss of response to Remicade. However, management of ulcerative colitis using the Anser IFX has not been standardized, and recommendations for management based on test results have not been formed (Kornbluth and Sachar). In addition, the use of Anser IFX to direct treatment has not been clinically proven to improve patient outcomes or alter patient management in high-quality controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies (Adedokun, et al). One study, with some patients undergoing dose intensification following initial non-response, showed no difference in serum levels of infliximab between patients who responded to dose intensification versus those who did not (Pariente, et al). Based on the clinical literature, the Anser IFX testing performed on 11/11/15 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

4f9a2c7802f38acdf47b20f9fb60c60d

./data/processed/ca_cdi/summaries/16-4740.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 38-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 11/11/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that the use biologics such as Remicade in ulcerative colitis has been proven. However, when a patient loses response to Remicade, this may entail increasing the dose. In this case, there is concern as the disease is active and the patient is symptomatic. The concern between total loss of response, low antibody level to the biologic, or a completely different diagnosis entails completely different measures varying from change or increase in dose of biologic to alternate treatment. Moreover, it has been shown in the medical literature that checking for such antibodies helps optimize clinical response by helping achieve a more optimal drug concentration. Given this support, the Anser IFX testing performed on 11/11/15 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

4f9a2c7802f38acdf47b20f9fb60c60d

./data/processed/ca_cdi/summaries/16-4740.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer A 52-year-old female enrollee has requested reimbursement for bilateral reduction mastopexies provided on 3/21/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bilateral macromastia with ptosis. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records do not document that the patient had typical signs and symptoms associated with functional impairment related to macromastia. There was no medical description of pain, shoulder grooving, chronic rashes or other signs and symptoms to support that the planned procedure was reconstructive surgery. Thus, bilateral reduction mastopexies provided on 3/21/17 was 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

3ea687a412e57e88ae152c665b92f650

./data/processed/ca_cdi/summaries/18-6420.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer A 64-year-old female enrollee has requested reimbursement for residential mental health services provided from 4/6/15 through 5/5/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the residential mental health services provided from 4/6/15 through 5/5/15 were not medically necessary for treatment of the patients medical condition. The documentation submitted for review does not support the initial residential placement. The patient felt isolated and limited in her pursuit of quality of life activities in caring for her husband. However, she did have a supportive brother and was motivated for treatment. Although formidable in its persistence and intensity, there was no mention of a change in the symptom complex. The patient was seeing a psychiatrist in the community, but the extent of non-pharmacologic interventions, including respite care, was not reported. Further, the patient was not seeing a psychologist or therapist at the time of admission. Finally, the patient had not failed a less restrictive treatment setting, such as partial hospitalization or an intensive outpatient program, during this episode of illness. This is significant in this case for two reasons: first, current psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment; second, there was no evidence to suggest that a less restrictive treatment setting would have been insufficient. Thus, the residential mental health services at issue were not medically necessary for treatment of the patients behavioral health condition. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

fc272944805ffcae3f16a2ca761ef2ff

./data/processed/ca_cdi/summaries/16-4442.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer The parent of an 11-year-old male enrollee has requested authorization and coverage for orthoptic and pleoptic training. 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 fails to demonstrate the medical necessity of the requested services. The patients optometric record carries no diagnosis of ocular pathology, only the functional diagnosis of convergence excess. There is no documentation provided of any illness, injury, or significant organic malfunctioning of the patients eyes. The providers letter indicates that the patient has several psychological disorders. There is insufficient evidence supporting the medical efficacy of the requested orthoptic and/or pleoptic training. Per the American Academy of Ophthalmology, there is a lack of evidence-based information supporting the effectiveness of vision therapy. Vision therapy is not within the standard of medical care for children with reading difficulties, attention problems, or other psychological disorders. Therefore, the requested orthoptic and/or pleoptic training is not medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

7d248375b7487b1283273d807d41faec

./data/processed/ca_cdi/summaries/19-6877.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 57-year-old male enrollee has requested gene testing performed on 9/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma. The physician reviewer found that the testing performed in this case is a study of 15 to 31 genes in an individuals melanoma cells. It has been used to classify that melanoma as having either a high or low risk of metastasis. Per the medical evidence, this testing is particularly useful in the analysis and clinical follow-up of uveal melanoma. This has been validated in several studies and has become a standard test in this setting. Its clinical value lies in determining the need for intense surveillance and possibly to assist in the decision as to adjuvant therapy. Thus, gene testing performed on 9/11/17 was likely to have been more efficacious 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

5449b8f72c342280620867036faef27d

./data/processed/ca_cdi/summaries/18-6360.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 57-year-old male enrollee has requested gene testing performed on 9/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma. The physician reviewer found that local treatment for primary uveal melanoma is effective in preventing local recurrence in over 95 percent of cases, yet up to 50 percent of patients are at risk for metastatic disease. The high risk of metastatic disease is thought to be due to a propensity for early micrometastasis followed by a variable latency period prior to the emergence of overt metastatic disease. Gene expression profiling (GEP) has been shown to be superior to chromosomal markers, as well as clinical and histopathological prognostic factors, for defining groups at high risk for the development of metastatic disease. Using primary uveal melanoma samples obtained by fine needle biopsy, GEP classifies tumors as having low (class 1) or high (class 2) metastatic potential depending on the expression of 12 discriminating genes and three control genes. This profile test is considered a standard of care. In sum, gene testing performed on 9/11/17 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

5449b8f72c342280620867036faef27d

./data/processed/ca_cdi/summaries/18-6360.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 57-year-old male enrollee has requested gene testing performed on 9/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The only clinical information available for review are the requisition and report of test results. Per the medical evidence, management includes surveillance testing. However, there was insufficient information submitted to determine if there were other features of the patients clinical situation that would make him moderate or high risk. Therefore, there is insufficient information to determine whether the services at issue were likely to be more beneficial than any available standard therapy. Thus, gene testing performed on 9/11/17 was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

5449b8f72c342280620867036faef27d

./data/processed/ca_cdi/summaries/18-6360.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer A 50-year-old female enrollee has requested authorization and coverage for stretching devices (E1830 and E1399). The Health Insurer has denied this request indicating that the requested devices are not medically necessary for treatment of the enrollees medical condition status post hammertoe correction. The physician reviewer found that the requested Dynasplint toe flexion system stretching devices are not medically necessary for treatment of the patients condition. There is a lack of sufficient evidence in the published medical literature to permit conclusions on the safety, efficacy and long-term outcomes of the proposed stretching devices. In this case, the use of static progressive stretch splint devices alone or combined with standard physical therapy is not medically necessary. In addition, there is a lack of documentation demonstrating that the patient is unable to benefit from standard physical therapy modalities because of an inability to exercise or the patient has participated in a treatment plan with documentation of no improvement for four months. Moreover, the use of patient-actuated serial stretch and bi-directional static progressive devices is not the standard of care in this clinical setting. All told, the request for stretching devices (E1830 and E1399) has not been established as medically necessary for the patients medical condition. Therefore, the requested devices are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

654a4ff2b08be3fca56c768a056837cb

./data/processed/ca_cdi/summaries/18-6196.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 59-year-old female enrollee has requested reimbursement for Decision DX melanoma assay performed on 5/19/16. 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 prognosis of cutaneous melanoma has classically been determined by the applying the staging system spelled out by Balch. Mitotic index has also been thought to add to these statistics. By Balch tables, this patients melanoma would be classified as a T1a melanoma, or stage 1A. Such a tumor would have a predicted ten year survival of at least 88%. Decision DX melanoma assay is a study of 31 genes in melanoma cells. It then classifies that particular melanoma as either Class 1 (with a 97% disease free rate at five years) or Class 2 (with a 20-30% disease free rate at five years). Gerami reported on 217 cases, with good correlation between prognosis and Decision DX classification, in patients undergoing sentinel node sampling. However, it is not clear as yet how Decision DX data compares to the ten-year data of Balch determinations, and whether it can be used additionally to make clinical decisions. This is especially in question in this particular patient, given her pathologic findings and excellent prognosis. Thus, Decision DX melanoma assay performed on 5/19/16 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

8c7263c2115aae38ab834e19db4ad549

./data/processed/ca_cdi/summaries/17-4944.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 59-year-old female enrollee has requested reimbursement for Decision DX melanoma assay performed on 5/19/16. 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 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, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but they suggest 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 Decision DX melanoma assay 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. The test is very novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Therefore, Decision DX melanoma assay performed on 5/19/16 was not likely to have been more efficacious 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

8c7263c2115aae38ab834e19db4ad549

./data/processed/ca_cdi/summaries/17-4944.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 59-year-old female enrollee has requested reimbursement for Decision DX melanoma assay performed on 5/19/16. 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 that the decision DX melanoma assay has been developed in patients with stage I and II cutaneous melanoma. However, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. It does not aid in the decision for re-excision. In sum, Decision DX melanoma assay performed on 5/19/16 was not likely to be of greater benefit than available standard therapy. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

8c7263c2115aae38ab834e19db4ad549

./data/processed/ca_cdi/summaries/17-4944.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer An 18-year-old male enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 11/16/17 through 1/04/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal at any time, although he had recent passive suicidal ideation without intent to harm himself. With regards to functional status, the records support a score of 2. The patient has had some issues with level of function that were sporadic nature. He showed intact activities of daily living. In terms of comorbidity, the records support a score of 1. The patient does not have active medical problems or substance use. With regards to level of stress of the recovery environment, the records support a score of 2. There was no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. It appears that the patient has had minimal prior treatment and was cooperative in the residential treatment center program at issue. In terms of acceptance and engagement, the records support a score of 2. The patient actively participated in therapy on admission. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient had a composite score of 16. This score correlates with intensive outpatient services. Therefore, residential mental health treatment for children and adolescents provided from 11/16/17 through 1/04/18 was not medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

58754e403b2b35276ad9717426656fe3

./data/processed/ca_cdi/summaries/19-6706.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer A 47-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. The current medical evidence supports the requested medication in this clinical setting. All told, Harvoni is medically indicated for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

23103d74987197fb03416eb5aff13f56

./data/processed/ca_cdi/summaries/15-4269.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer The patient is a 57-year-old female with a history of left knee pain. The patient has requested authorization and coverage for left knee arthroscopy with partial meniscectomy and chondroplasty. 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 recent studies have conclusively shown that outcomes after an arthroscopic partial meniscectomy are no better than the outcomes after a sham/placebo surgery. Meniscal repair is now being touted as a viable and effective alternative. However, meniscal repairs depend upon the location of tear in the peripheral red zone of the meniscus. Meniscal repairs have been proven to be a much more efficient alternative to partial meniscectomy. It is now increasingly recommended to attempt meniscal repair in all repairable tears, especially in young and physically active patients. Partial meniscal implants have also shown excellent outcomes in long-term studies, but its efficacy in acute settings still requires further research. Research in regenerative medicine also looks promising for the meniscal tissue. In this case, the patient has documented degenerative changes in the medial articular surface of the patella and trochlea. The two reported tears are small and involve the inferior aspect of the medial meniscus in the posterior horn and the body. These are likely degenerative in nature. There are no mechanical symptoms documented, and the tears are stable. Focal cartilage lesions seen on MRI, such as fissuring in this case, warrant a trial of conservative treatment, such as physical therapy, home exercise program, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections or viscosupplementation, which has not been documented. Furthermore, the location of pain has not been documented to be anterior, and so it is not known if patellar chondromalacia is the pain generator. Chondroplasty has short-term efficacy for pain relief and may be done as a part of the arthroscopic procedure of partial meniscectomy, which is not indicated for the aforementioned reasons. Therefore, the requested left knee arthroscopy with partial meniscectomy and chondroplasty is not medically necessary for the treatment of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

665a2ce833886e990c74e6b086979bc0

./data/processed/ca_cdi/summaries/21-7345.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer The patient is a 46-year-old female who has been diagnosed with metastatic signet ring cell adenosarcoma. The patient was initially diagnosed in November 2016. She is currently being treated with folinic acid, fluorouracil and oxaliplatin (FOLFOX) chemotherapy. Prior therapies have included bilateral ureteral stenting, folinic acid fluorouracil and irinotecan (FOLFIRI) and paclitaxel with ramucirumab. Based on a molecular profiling performed with FoundationOne testing, the provider recommended treatment with Cabometyx. The Health Insurer denied the request for coverage and authorization on the basis that the requested Cabometyx 60 mg is not medically necessary for the treatment of this patients medical condition. This denial is the subject of this appeal and determination. There is a lack of support for the requested medication in this clinical setting. Cabometyx (cabozantinib) is not U.S. Food and Drug Administration approved for the treatment of gastric cancer. Off-label use is not supported by major drug compendia or the National Comprehensive Cancer Network guidelines. In addition, the medical literature does not reveal clinical trials that support the use of cabozantinib for patients who are diagnosed with gastric cancer. As such, the efficacy of Cabometyx 60 mg for treatment of this patients medical condition has not been established. Therefore, for the reasons stated above, Cabometyx 60 mg is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

698e20438574a4fc92ab841dd07ab02f

./data/processed/ca_cdi/summaries/18-6279.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 45-year-old male enrollee has requested authorization and coverage for powered upper extremity range of motion assist device, elbow, wrist, hand and finger. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the standard of rehabilitative care in the setting of central nervous system pathology such as stroke resulting in severe functional impairments is to directly address these impairments and optimize overall function, as well as to mitigate the risks of health complications. Depending on the impairments specific to a case, increased independence can be achieved using equipment, such as assistive speech technology, adaptive utensils, nonskid plates, gait/mobility implements, wheelchairs, and other adaptive equipment and accessibility/environmental modifications, if/when appropriate. When there are limits to function despite exhausting more direct interventions, or when efficiency or safety call require it, caregivers may be called upon to otherwise meet a personas functional needs.There is no proven role of the MyoPro elbow-wrist-hand-finger orthosis in stroke management or rehabilitation. The proposed device does not replace the role of conventional (i.e., passive, light and custom-fitted) orthoses, which can be employed as needed to manage the effects of tone, to reinforce therapeutic positioning, and to enhance functionality when applicable. The device in question is not expected to practically assist a user in self-care tasks such as grooming, bathing, dressing, or other tasks requiring dextrous upper extremity use. Given the weight, bulk, and delayed responses effectuated by the device in question, adoption of the device for regular functional use on a long-term basis is not expected to be likely. There are, moreover, potential adverse sequelae and safety issues related to this device, including the potential to cause or exacerbate edema, skin injuries, musculoskeletal injuries or pain, including hemiplegic shoulder pain. Hemiplegic shoulder pain, in particular, is highly prevalent following stroke, affecting up to 50% of this population. Its etiology is multifactorial, but glenohumeral subluxation is an important factor. Risk factors for shoulder subluxation and hemiplegic shoulder pain include increased levels of weakness, i.e., shoulder muscles that are too weak to adequately support the weight of the upper limb against gravity. The device in question can add approximately 50% to the weight of an arm, which would increase the risk of subluxation and hemiplegic shoulder pain. In addition, the safety of using this device while standing or walking in persons who have impaired lower limb strength and balance due to stroke with hemiparesis is unclear. Falls could be potentially precipitated in device users with unexpected disturbances in their center of gravity that cannot be adequately compensated for while using the heavy device due to stroke-related impairments in balance and the hemiparetic trunk and lower limb. There are, overall, no functional benefits that would be expected from the use of this device. There are potential risks of injury associated with use of this device, as discussed above. There is a lack of proven health benefits associated with the use of this device. The available scientific evidence related to the type of orthotic device in question is limited to preclinical work and anecdotal literature. The requested device is not likely to be more beneficial for treatment of the patientas medical condition than any available standard treatment and rehabilitation for chronic functional impairment following severe stroke, which would include the devices and supportive care discussed above. Therefore, the requested powered upper extremity range of motion assist device, elbow, wrist, hand and finger is not likely to be more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

5860110bf9dcbbe9236a168b168350f5

./data/processed/ca_cdi/summaries/20-7178.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 2 A 45-year-old male enrollee has requested authorization and coverage for powered upper extremity range of motion assist device, elbow, wrist, hand and finger. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a lack of support for the requested device in this clinical setting. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve his hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase his participation in bimanual activities. Winstein and colleagues reviewed the various treatments of motor dysfunction after a stroke. The authors noted that a Cochrane review found that upper limb robotic therapy provided some benefit with regard to activities of daily living and arm function, but not arm muscle strength. The guidelines indicate that these studies were noted to have numerous limitations. These limitations include the variation within the trials with regard to duration and amount of training, the specific devices used, and patient populations studied limit the interpretation of these results. McCabe and colleagues performed a small study that was retrospective with inconsistent timing of testing and limited interpretation. The authors discussed the feasibility and clinical experience of using myoelectric orthosis in rehabilitation of chronic stroke patients. The study used a small patient group and indicated that additional studies are warranted to determine the effectiveness of these methods in the clinical setting. Additional controlled studies of the MyoPro Orthosis for upper extremity paralysis after a stroke are needed with larger patient groups, consistent improvements of relevant outcome functional measures, and long-term follow-up. Therefore, the requested powered upper extremity range of motion assist device, elbow, wrist, hand and finger is not likely to be more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

5860110bf9dcbbe9236a168b168350f5

./data/processed/ca_cdi/summaries/20-7178.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 3 A 45-year-old male enrollee has requested authorization and coverage for powered upper extremity range of motion assist device, elbow, wrist, hand and finger. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that current quality evidence shows that the use of the myoelectric elbow-wrist-hand orthosis increases gross manual dexterity, increases the quality of task performance and enables subjects to grasp objects like a cup significantly faster. Myoelectric elbow-wrist-hand orthosis facilitates clinically meaningful increases in functional task performance. Moderately impaired stroke survivors exhibit severely diminished ability to incorporate their affected upper extremities into daily activities and subsequently have limited treatment options. This limitation often necessitates prescription of compensatory strategies and/or assistive devices to facilitate independence, with limited involvement from the paretic upper extremity, making many activities extremely difficult. In contrast, current evidence supports that paretic arm disability may be significantly reduced while wearing a myoelectric elbow-wrist-hand orthosis, allowing for immediate use of the paretic arm and hand with little device training. Therefore, the requested powered upper extremity range of motion assist device, elbow, wrist, hand and finger is likely to be more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

5860110bf9dcbbe9236a168b168350f5

./data/processed/ca_cdi/summaries/20-7178.jsonl

Insurer Denial Upheld

Experimental

Summary Reviewer 1 A 51-year-old female has requested reimbursement for destruction by neurolytic agent (CPT codes 64635 and 64636) performed on 12/02/13 and 12/23/13. 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 records indicate that the patient underwent cooled radiofrequency lesioning. Of note, cooled radiofrequency lesioning is a newer technology that does not have the same peer-reviewed evidence of duration and efficacy as conventional radiofrequency lesioning. Although the current literature on cooled radiofrequency lesioning is promising, more extensive studies need to be conducted against the standard approach. Therefore, the services at issue performed on 12/02/13 and 12/23/13 were not likely to be of greater benefit than other treatment alternatives. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

d93764d25e08ab37097856884e559f57

./data/processed/ca_cdi/summaries/16-4611.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 51-year-old female has requested reimbursement for destruction by neurolytic agent (CPT codes 64635 and 64636) performed on 12/02/13 and 12/23/13. 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 there is sufficient support for the services at issue in this patients case. Lumbar medial branch radiofrequency ablation or neurolysis is a well-documented procedure which may help with chronic low back pain due to lumbar facet pain. The medical records support the services at issue in this clinical setting. The literature has noted the effectiveness of medial branch radiofrequency neurotomy in systematic reviews and randomized trials. In sum, the services at issue performed on 12/02/13 and 12/23/13 were likely to have been more effective 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

d93764d25e08ab37097856884e559f57

./data/processed/ca_cdi/summaries/16-4611.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 51-year-old female has requested reimbursement for destruction by neurolytic agent (CPT codes 64635 and 64636) performed on 12/02/13 and 12/23/13. 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 there is sufficient support for the services at issue in this clinical setting. This patient had both axial and radicular pain complaints. The right lumbar medial branch nerve blocks and cooled lumbar medial branch nerve radiofrequency ablation at L3, L4, and L5 were aimed at the axial component of the back pain. Radiofrequency ablation is a standard, widely accepted treatment for axial lumbar back pain. Thus, the services at issue performed on 12/02/13 and 12/23/13 were likely to have been superior over other treatment alternatives. 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

d93764d25e08ab37097856884e559f57

./data/processed/ca_cdi/summaries/16-4611.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 1 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 this patient presented with a longstanding history of bilateral severe hallux valgus deformity, left greater than right. She complained of pain with weight-bearing. Conservative treatment had included activity modification, bracing, wide shoes, and nonsteroidal anti-inflammatory drugs. She had a left hallux valgus angle (HVA) of 35 degrees, and intermetatarsal angle (IMA) of 15 degrees. She had a right HVA of 35 degrees, and intermetatarsal angle (IMA) of 18 degrees. She underwent left chevron osteotomy and modified McBride procedure with x-ray fluoroscopy on 6/10/19, and right scarf osteotomy and modified McBride procedure with x-ray fluoroscopy on 7/29/19. Current evidence-based medical literature supports the use of surgical treatment of hallux valgus in this clinical setting, given the severity of the HVA and IMR angles, significant pain and functional impairment, and failure of non-operative treatment. Additionally, there is no indication in the literature to support ongoing conservative treatment over surgical correction in the setting of severe deformity. Therefore, 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

fb888070fdad492148aef89ff037d5ac

./data/processed/ca_cdi/summaries/20-6969.jsonl

Insurer Denial Overturned

Experimental

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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

fb888070fdad492148aef89ff037d5ac

./data/processed/ca_cdi/summaries/20-6969.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 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 this patient had a history of bilateral hallux valgus deformities, and she underwent surgery for correction of this painful deformity. The provider elected to perform the modified McBride procedure combined with a chevron osteotomy of the left great toe on 6/10/19 and a modified McBride procedure combined with a scarf osteotomy of the right great toe on 7/29/19. Fluoroscopy was utilized for both surgical procedures. Hallux valgus deformity is a common chronic problem, and its chief complaint is pain. The procedures performed, including the modified McBride, chevron osteotomy, and scarf osteotomy, are all current procedures with documented good results. There is sufficient support for the services at issue in this clinical setting. Thus, 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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

fb888070fdad492148aef89ff037d5ac

./data/processed/ca_cdi/summaries/20-6969.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer A 60-year-old male enrollee has requested reimbursement for Oncotype DX Genomic Prostate Score performed on 5/16/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) recommends that men who are status post biopsy with low or favorable intermediate risk disease may consider the use of the Oncotype DX testing. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. Therefore, the Oncotype DX Genomic Prostate Score performed on 5/16/19 was medically necessary for the evaluation of this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

a9a38e5c1268eeca30d8bdbda3d92415

./data/processed/ca_cdi/summaries/20-6949.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer A 64-year-old male enrollee has requested reimbursement for air ambulance transport on 7/19/14 through 7/20/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the review of the submitted evidence demonstrates the patient was involved in a serious motor vehicle accident on 7/2/14, resulting in multiple life-threatening injuries and requiring air transportation to the nearest hospital for stabilization and intensive medical treatment. The patients condition initially required placement on life support with subsequent sedation and was further complicated by underlying medical problems, such as a history of prior lung cancer. Open and active communication among the members of the medical team and the family, and later with the injured person, is of significant importance in this setting in order to consistently match the medical care to the injured persons needs and goals and to maximize subsequent recovery. Further, these extensive injuries typically require prolonged and aggressive medical treatment in order to have the best possible ultimate recovery, function and speech, and ability to think clearly. According to the submitted documentation, the hospital nearest to the accident site was able to provide the technical medical skills that the patient required. However, the significant language barrier prevented the open and active communication that was necessary, and this was likely to interfere with the patients overall medical care and subsequent recovery. Transportation to a facility that had English-speaking medical team members was therefore necessary. However, there were a number of such facilities in Italy and other nearby countries that could meet these criteria. Further, the patients overall condition at the time of the transfer was somewhat tenuous. Shorter transportation time may have placed less physical stress on the body while in this state and would have also returned the patient to a more controlled intensive medical environment faster. For these reasons, air ambulance transportation from Pisa, Italy to the receiving hospital in California was not medically necessary. For the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

cf623bc01ffe200bbbb95e5ce8d8694a

./data/processed/ca_cdi/summaries/15-4136.jsonl

Insurer Denial Upheld

Medical Necessity

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.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

7f143d470b3cce24c05c8d18663950c3

./data/processed/ca_cdi/summaries/18-6204.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer A 51-year-old female enrollee has requested reimbursement for mental health residential treatment from 5/13/15 through 6/07/15. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees alcohol use disorder. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue. In this case, the patients alcohol use disorder was complicated by co-occurring mood and anxiety disorders. He alcohol use dominated her daily routine and generated distress. Further, her drinking negatively impacted her health, strained meaningful relationships, and caused significant impairment across multiple domains of functionality. Additionally, her motivation and social supports were limited. In this patients case, the residential treatment provided was safe, appropriate and consistent with good practice. Additionally, the services provided during the disputed timeframe were for active treatment, and reasonably expected to improve her condition and prevent a more serious episode of illness. Further, the duration of the disputed treatment course was within community practice standards. All told, mental health residential treatment provided from 5/13/15 through 6/07/15 was medically indicated for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

728fb830bfc495e0c7c474201d359183

./data/processed/ca_cdi/summaries/15-4163.jsonl

Insurer Denial Overturned

Medical Necessity

Summary Reviewer The parent of a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center (RTC) services provided from 11/7/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and anxiety. The physician reviewer found that based on current guidelines including the Child and Adolescent Level of Care Utilization System (CALOCUS), the RTC services provided from 11/7/16 forward were not and are not medically necessary for treatment of this patients medical condition. As noted by the CALOCUS, the patient was at some risk of harm due to episodic outbursts but is not having active suicidal ideation or other behaviors or thoughts. In addition, the patients functional status is moderate, the patient has had minimal school disruption and is able to complete activities of daily living in an age appropriate manner. Further, the patient does not have active serious medical problems and although he has issues with family relationships, he has a stable housing situation if accepted home. The patients resiliency and treatment history is moderate due to minimal positive treatment response in the past and the patient participates actively in therapy but has poor insight and is obstructive at times. Overall, this patients presentation supports treatment in a less restrictive setting such as intensive outpatient program (IOP). It appears that the patient has sufficiently stabilized to allow transition to a less restrictive setting. The majority of the patients current issues are due to continued oppositional behaviors and the patient has made progress related to his treatment goals. The patients goals are similar to those that would occur on an outpatient basis. Accordingly, the medical records do not support the medical necessity of the RTC services provided from 11/7/16 forward for treatment of this patients behavioral issues. Based on the available documentation, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

5153881ee0fd50a0065a09458f872a1b

./data/processed/ca_cdi/summaries/17-4845.jsonl

Insurer Denial Upheld

Medical Necessity

Summary Reviewer 1 A 38-year-old male enrollee has requested reimbursement for genetic testing performed on 5/31/18. 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 while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. The relatively new development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. Among these tests is ThyGenX, which analyzes a panel of DNA mutations and RNA translocation fusion markers to assess the risk of malignancy with good negative and positive predictive value, thereby obviating the need for unnecessary surgeries. Therefore, genetic testing performed on 5/31/18 was likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

22334cf6751841c21cfccf6683f6aab2

./data/processed/ca_cdi/summaries/20-7031.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 2 A 38-year-old male enrollee has requested reimbursement for genetic testing performed on 5/31/18. 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 molecular testing has emerged as a promising method for clarifying the gray area of indeterminate thyroid fine needle aspirations, with the aim of reducing the overtreatment of benign nodules and increasing the preoperative detection of malignant nodules that should be treated by a single surgery (total thyroidectomy) rather than a two-step procedure. When molecular testing informs patient management, it should be further integrated with clinical findings and ultrasonographic results. As additional information accumulates to further refine these integrated approaches to patient management, the genetic information provided by molecular tests is expected to increasingly individualize the management of patients with thyroid nodules and cancer. In this patients case, a second thyroid biopsy was not necessary because this test was done as a follow-up of an indeterminate result. A benign result by the ThyGenX/ThyraMIR test has a significant negative predictive value. The medical evidence supports the services at issue in this clinical setting. All told, genetic testing performed on 5/31/18 was likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

22334cf6751841c21cfccf6683f6aab2

./data/processed/ca_cdi/summaries/20-7031.jsonl

Insurer Denial Overturned

Experimental

Summary Reviewer 3 A 38-year-old male enrollee has requested reimbursement for genetic testing performed on 5/31/18. 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 there is sufficient support for the services at issue in this clinical setting. This patients initial biopsy was suspicious for follicular neoplasm. Genetic testing could obviate the need for a surgical procedure. Genetic testing on thyroid nodules is generally considered standard protocol on all fine needle aspirations done on thyroid nodules. The literature indicates that this testing can be performed to avoid unnecessary surgeries. The results from this testing may influence patient management. Thus, genetic testing performed on 5/31/18 was likely to have been more beneficial than other methods of evaluating this patient.

2024-02-03

https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1::

22334cf6751841c21cfccf6683f6aab2

./data/processed/ca_cdi/summaries/20-7031.jsonl

Insurer Denial Overturned

Experimental