The carrier has denied coverage for the Prometheus Anser ADA testing performed on 07/31/2015 as experimental and/or investigational and not medically necessary. A letter from the carrier to Prometheus Laboratories, Inc., dated 04/01/2016, states in part:
“We were unable to approve the reprocessing of the claim for laboratory services submitted for the date of service July 31, 2015, because the claim processed correctly according to Humana 's Medical Coverage Policy, Colorectal Cancer Screening, which states the Anser ADA test requested is not considered the standard of care and is considered investigational. As a result, we have upheld the original processing of the claim. You can view the processing of the claim on the enclosed Health Benefits Processing Chart.
The Benefit Plan Document states unless specifically stated otherwise, no benefits will be provided for, or on account of, the following items:
• Any drug, biological product, device, medical treatment, or procedure which is experimental or investigational or for research purposes.”
There is a letter from Prometheus Laboratories, Inc., dated 02/24/2016, that states in part:
“Marc Sonenshine has been treating Matthew Miles with Adalimumab by subcutaneous injections. He has recently begun to exhibit symptoms that may indicate a loss of response to this treatment which may be due to sub-therapeutic levels of Adalimumab (ADA) or the presence of antibodies to adalimumab (ATA).
Based on the patient’s history as well...
... middle of paper ...
... approach has been shown to result in better outcomes and at less cost than empirical attempts at dose intensification or switching within class.
Therefore, the carrier’s decision to deny coverage for the Prometheus Anser ADA testing performed on 07/31/2015 as experimental and/or investigational was not appropriate.
The Prometheus Anser ADA testing performed on 07/31/2015 was medically necessary for the treatment of this member’s condition.
The expected benefit of the recommended or requested health care service or treatment is more likely than not to be beneficial to the member than any available standard health care service or treatment.
The adverse risks of the recommended or requested health care service or treatment are not substantially increased over those of available standard health care services or treatments.
The previous denial should be overturned.
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