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Explore Our White Papers for Payer Organizations

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AllMed's white papers serve as companions to our clinical webinars that are designed to help our clients stay abreast of emerging clinical procedures and therapies to support improved clinical decision making.

Marketing Page Treating Clinical Obesity: When is Bariatric Surgery or Bariatric Surgery Revision Medically Necessary?
The incidence of obesity continues to increase in the United States, along with other related health problems, placing an enormous strain on the healthcare system. Patients who do not lose weight with traditional weight management approaches may turn to bariatric surgery procedures, such as gastric bypass and laparoscopic adjustable gastric banding. Although bariatric surgery can effectively treat obesity by helping patients achieve substantial, sustained weight loss, many health plans cover these procedures only when individuals meet very specific criteria and have well-documented failure of medical management.
Marketing Page Breast Cancer Preventive Care: When is Prophylactic Mastectomy Medically Necessary?
Improvements in risk reduction measures and early detection of cancer through screening have resulted in decreased cancer incidence and mortality in the United States. Prophylactic mastectomy has been a mainstay of preventive care for women at very high risk of breast cancer. The potential benefits of the procedure, however, may be limited in women who are not at high risk.
Marketing Page Treating Chronic Sinusitis: When is Balloon Sinuplasty Medically Necessary?
Despite advances in instrumentation and technology, the management of chronic sinusitis and related conditions remains challenging for both physicians and patients, especially as treatment guidelines and recommendations continue to evolve. Although balloon sinuplasty has been shown to be safe and effective in a number of studies, its use has not yet gained widespread acceptance as a standard of care for the treatment of patients with chronic sinusitis.
Marketing Page Indications for Lumbar Fusion: Establishing Standards for Medical Necessity
The annual number of spinal fusion operations performed in the United States has increased by more than 80% in the past decade. Off-label use of spinal procedures has also increased. Although a number of conditions of the spine benefit from lumbar fusion, some off-label uses are associated with inconsistent outcomes and significant potential risks and complications.
Marketing Page Treating Gastroesophageal Reflux Disease (GERD): When Is the LINX Reflux Management System Medically Necessary?
The LINX Reflux Management System was approved in 2012 as a minimally invasive alternative to Nissen fundoplication, which has long been the surgical gold standard for patients with gastroesophageal reflux disease (GERD) that has not been responsive to medical therapy. Many health plans, however, still consider the LINX device experimental and investigational for the management of GERD. This may change, however, as long-term safety and efficacy data on the device have recently become available.
Marketing Page White Paper - Cervical Disc Replacement: When is the Mobi-C Cervical Disc Medically Necessary?
Cervical disc replacement has become an increasingly viable alternative to spinal fusion for select patients, as longer-term data and improved technology continue to emerge. The Mobi-C Cervical Disc is currently the only cervical intervertebral disc prosthesis that has been approved by the U.S. Food and Drug Administration to treat more than one level of the cervical spine.
Marketing Page White Paper - Treating Cataracts: When Are Intraocular Lens Implants Medically Necessary?
The current cataract procedure of choice involves removing the natural lens of the eye and implanting an IOL. The type of IOL used is dependent on physician recommendation and the visual needs of each individual patient. While monofocal IOLs are considered the standard and meet the basic functional needs of patients who undergo cataract removal, technological advancements have led to the development of other types of IOLs.
Marketing Page White Paper - Quality Improvement Initiatives for Managing Low Back Pain with Lumbar Artificial Disc Replacement: How to Minimize Risk and Improve Outcomes
Most quality improvement efforts in surgery focus on the technical quality of care provided, rather than on whether the care was indicated or whether an alternative procedure could have been performed. Because risk is inherent in any procedure, reducing the number of unnecessary lumbar artificial disc replacements is an important issue in patient safety. Reducing the number of unnecessary surgeries can improve the efficacy of these procedures, as well as prevent significant potential risks and complications.
Marketing Page White Paper - Blepharoplasty: When Is Eyelid Surgery Medically Necessary?
Blepharoplasty, or eyelid surgery, is commonly performed for cosmetic reasons to improve appearance. However, in some cases, the surgery may be necessary to remove overhanging skin folds to improve the function of the upper eyelid, as well as to improve vision. Although definitions for medically necessary blepharoplasty can vary by health plan, all patients must meet specific documentation requirements, with many plans requiring visual field testing.
Marketing Page White Paper - Pediatric Physical, Occupational, and Speech Therapy: When Are These Rehabilitation Services Medically Necessary?
Children who need rehabilitation services often have complicated healthcare needs that put them at risk for chronic physical, developmental, and behavioral conditions. The concept of rehabilitative therapy includes recovery or improvement in function and, when possible, restoration to a previous level of health and well-being. Therefore, evaluation, re-evaluation, and assessment must be clearly documented to rationalize the initation of treatment or to justify continued treatment.
Marketing Page White Paper - Wearable Cardioverter-Defibrillators: When Are They Medically Necessary?
As many as 20% of patients in the United States who receive an implantable cardioverter-defibrillator (ICD) do not meet current guidelines for patient selection, which increases risk of mortality and serious complications. While WCDs are designed to perform the same functions as ICDs and are noninvasive, careful patient selection remains critical in order to avoid potential complications, as well as to improve the efficacy of these devices.
Marketing Page White Paper - Managing and Treating Hepatitis C: When Is Olysio (Simeprevir) Medically Necessary?
The U.S. Food and Drug Administration (FDA) recently expanded the indications for simeprevir so that it can be used as part of a new direct-acting treatment combination. As the treatment of HCV continues to evolve, new and more complex protocols present additional challenges in providing optimal care while meeting the unique needs of individual patients.
Marketing Page White Paper - Stereotactic Body Radiation Therapy (SBRT): When Is SBRT Medically Necessary?
Advances in stereotactic radiation techniques have resulted in safer delivery of high doses of radiation to extracranial sites with reduced toxicity and improved outcomes. The clinical applications of SBRT, however, currently remain limited. Some clinicians may attempt to justify the use of SBRT for certain types of cancers based on results from small studies that lack sufficient data.
Marketing Page White Paper - Influenza Treatment Guidelines Update: When Are Antiviral Agents Medically Necessary?
The Centers for Disease Control and Prevention continues to recommend annual vaccination as the best tool for preventing influenza, as well as timely use of antiviral medications to treat influenza in select patients. While antiviral drugs can help reduce the duration and severity of flu symptoms, the decision to use them must be based on individual evaluations of risk and benefit.
Marketing Page White Paper - Diagnosis and Management of Obstructive Sleep Apnea: When are Sleep Studies Medically Necessary?
Estimates indicate that as many as 18 million Americans suffer from sleep apnea. Sleep abnormalities can lead to declines in quality of life, diminished waking performance, more frequent illness, and increases in both morbidity and mortality. Despite the high prevalence of sleep disorders, sleep complaints often remain under-addressed.
Marketing Page White Paper - Intensity-Modulated Radiation Therapy (IMRT): When Is IMRT Medically Necessary?
IMRT controls, or modulates, the intensity of the radiation beam to match the exact 3D geometrical shape of the tumor, including concave and complex shapes. The use of IMRT has increased significantly in the past decade. Although data support the use of IMRT to optimize outcomes and reduce toxicities for certain cancers, the procedure has recently come under government scrutiny for its high cost and because some physicians refer patients to facilities in which they have ownership stake.
Marketing Page White Paper - The Use of Erythropoiesis-Stimulating Agents (ESAs) for the Treatment of Anemia of Chronic Kidney Disease: When are ESAs Medically Necessary?
Although the use of ESAs to treat anemia of CKD can improve quality of life and may eliminate the need for blood transfusion and its associated risks, it is not without controversy. Some studies suggest that ESAs may increase the risk of potentially life-threatening complications, such as cardiovascular disease. This has resulted in a recent shift toward a more cautious approach to prescribing ESAs for patients with anemia of CKD.
Marketing Page White Paper - The Use of Bone Morphogenetic Protein (BMP) in Lumbar Fusion: When is the Use of BMP Medically Necessary?
Spinal fusions are under more scrutiny than ever, as the use of BMP for lumbar fusion has increased significantly in recent years. While indicated in specific patient populations for lumbar fusion, BMP is often used off-label in surgeries for fusion of the cervical spine, which has been associated with numerous side effects and potentially life-threatening complications. The appropriate use of BMP requires careful consideration, taking into account its safety profile and high cost, as well as the data that studies continue to uncover.
Marketing Page White Paper - Determining Breast and Ovarian Cancer Susceptibility: When Are BRCA and BART Genetic Testing Medically Necessary?
While advances in genetic testing technology have improved detection rates for BRCA1 and BRCA2 mutations in individuals who are at high risk for breast and ovarian cancer, some mutations are missed with standard genetic testing. BART was developed to detect additional rare large genomic rearrangements in both BRCA1 and BRCA2, but most healthcare plans have not covered the cost of this additional test since it was introduced in 2006. This is changing, however, as new data continue to emerge supporting BART analysis in addition to BRCA1 and BRCA2 testing.
Marketing Page White Paper - Complex Regional Pain Syndrome (CRPS): Which Treatment Approaches are Medically Necessary?
Complex regional pain syndrome was once considered a controversial diagnosis. However, recent evidence suggests that CRPS is a multifactorial disorder that requires a multidisciplinary treatment approach, including pharmacotherapy, physiotherapy, and psychotherapy. The clinical heterogeneity of the disorder presents challenges in diagnosis and treatment, but further advances in understanding the multiple mechanisms implicated in the pathophysiology of CRPS will likely provide a basis for more targeted therapeutic interventions in the not-so-distant future.
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