Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast cancer (BRCA) gene test for evaluation of the enrollee, who has a family history of cancer. Findings: Two of the three physician reviewers found that the patient has a significant family history of cancer. The patient has also been examined for her predisposition. She has two maternal first cousins who tested positive for breast cancer (BRCA1) gene mutation. The patients mother is deceased. The patient has requested reimbursement for the BRCA gene test performed. The Health Plan denied reimbursement indicating that the services at issue were investigational for the evaluation of this patient. At the present time, genetic testing is not applied universally but rather to patients that exhibit family histories that are suggestive of inherited predispositions.  This patient has significant history of family members with BRCA gene mutation. BRCA testing is important in clinical oncology because bilateral mastectomy would eliminate a carriers chance of developing breast cancer.  Likewise, closer surveillance for ovarian cancer can be applied or the patient may choose salpingo-oophorectomy which would reduce the probability of developing this cancer.  A large study performed BRCA testing in 10,000 individuals and related the presence of mutations to the family history. They found that family history included at least one first or second degree relative with breast or ovarian cancer. Clinical guidelines criteria are not meant to be applied rigidly. They are based on the probability of finding mutations and there is an inherent risk of missing carriers. The criteria provides guidance but diagnosis needs to be individualized. Since this patient has an significant family history of cancer, it raises the suspicion of BRCA mutations in the family. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patient has a long history of depression, anxiety, and multiple psychiatric hospitalizations.  She has been tried on Prozac and Cymbalta without success.  She has had augmentation, and was in DBT and CBT for more than adequate periods of time.  The records show that she improved with TMS treatment. The Health Plan denied the treatment based on the patients age, stating that TMS is contraindicated for individuals less than 22 years old.  However, per the U.S. Food and Drug Administration use of TMS may be available for treatment of those patients younger than 22 years old. The following is noted, labeling should include precautions for the use of rTMS devices in the treatment of patients with depressive or related conditions where safety and efficacy has not been established age less than 22.  The FDA approval for TMS therapy does not preclude those patients younger than age 22. Instead, FDA recommends the use of precaution when prescribing this therapy for patients who are younger than 21-years-old. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Expedited Review: The parent of a transgender male enrollee has requested authorization and coverage for subcutaneous bilateral mastectomy procedure. The Health Plan has denied this request indicating that the requested procedure is not medically necessary and is not reconstructive in nature for treatment of the enrollees gender dysphoria. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Nature of Statutory Criteria/Case Summary: Based on the documentation provided, this patient has gender identity disorder and is documented to be an appropriate candidate for gender affirmation surgery. The patient reported that his dysphoria prevents him from going out in public. In this patients case, having normal appearance of the breasts, for a male, is the ultimate goal. While the Health Plan criteria provides that the patient should be 18 prior to undergoing surgical intervention, chronological age is not as important as the level of pubertal development. In this patients case, his breasts appear to be consistent with a teenage female. Testosterone has not resolved this patients breast enlargement.  Since the condition has not resolved, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate.  All told, this patient has evidence of abnormal breasts for a male and his medical condition will not likely improve with continued hormonal therapy. Thus, the subcutaneous bilateral mastectomy procedure is medically necessary for treatment of this patients gender dysphoria. With regard to whether the requested procedure is considered reconstructive in nature, the submitted documentation reveals that the patients breasts constitute an abnormal structure of a male body. This patient has well documented gender dysphoria and his breasts are developmentally abnormal for a male. The patients breasts should be more consistent with adult male breasts. Further, the plan of surgery will improve function and create a relatively normal appearing male chest. The proposed surgery will provide more than a minimal improvement in the appearance of this patient. Therefore, in this patients case, subcutaneous bilateral mastectomy procedure is reconstructive in nature.Final Result: The reviewer determined that the requested procedure is medically necessary and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee for evaluation of his left knee pain. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI. Per AIM guidelines, MRI of the left knee is not indicated unless the patient has completed a four to six week trial of medical therapy, including physical therapy. Although the patient had been taking NSAIDS for five weeks at the time of the left knee MRI request, the medical records do not document a trial of supervised physical therapy for his knee pain. Also, there is no documentation of any findings on physical exam that raise concern for a ligament tear. The reviewers determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator for treatment of his obstructive sleep apnea. Findings:  Three physician reviewers found that obstructive sleep apnea is an increasingly prevalent clinical problem with significant effects on both personal and public health.  Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy and low morbidity; long-term adherence rates approach 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation in animal and human subjects, the three-year and four-year results of a large multicenter, prospective trial were published in January 2016 and February 2017. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This trial has demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed CPAP, have an AHI between 20 to 50, have nonconcentric airway collapse and a write out BMI less than 32. However, with an AHI greater than 50, this patient does not meet the criteria. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in otolaryngology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa (sofosbuvir/velpatasvir 400 mg  100) mg for 12 weeks for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to 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 should be treated except those with life expectancy less than 12 months due to non-liver-related conditions, regardless of fibrosis stage. Per guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate (98%) with this regimen (Foster, et al). The guidelines no longer recommend Sovaldi with ribavirin as first-line therapy for genotype 3 hepatitis C. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hospital services. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received psychiatric emergency medical services on the dates of service in question. California law defines emergency services and care as an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. Based on the documentation submitted for review, the patient received psychiatric emergency medical services during the dates of service at issue. On admission the patient was status post smoking heroin outside of the hospital and in active withdrawals. She verged on being considered gravely disabled, although she was not admitted on a 5150. She was using, concomitantly, heroin, methamphetamine, cocaine, benzodiazepines, and cannabis. She had not attended to her activities of daily living and was found in an unhygienic condition, with syringes in her purse. She had a serious overdose episode which could have ended calamitously. As such, this patient was unable to undergo detoxification in a less restrictive setting as she was unable to control her impulses long enough to gain insight and develop a modicum of coping mechanisms. In addition, her blood pressure fluctuated on numerous occasions. She remained anxious and depressed. She continued to suffer from daily withdrawals despite being on the Suboxone taper. Given her condition at admission, her past history of polysubstance use, multiple serious relapses and escalating use, the services at issue were necessary for treatment of a psychiatric emergency medical condition. Thus, the patient received psychiatric emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient received psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gene testing (Decipher Test) for evaluation of the enrollees prostate cancer. Findings: Two of the three physician reviewers found that the request for gene testing is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Decipher is a genomic test that uses a whole-transcriptome microarray assay from formalin-fixed, paraffin-embedded prostate specimens. This signature was developed and validated as a predictor for clinical metastases after radical prostatectomy in men with adverse pathologic features. The main clinical utility of the test is to identify patients with adverse pathologic features who would benefit from salvage radiation therapy. However, data supporting clinical utility of this test in improving outcomes such as prostate cancer mortality, overall survival and treatment side effects in a prospective randomized controlled setting are lacking. The National Comprehensive Cancer Network (NCCN) guidelines recommend consideration of Decipher testing post prostatectomy for patients with pT2 with positive margins, any pT3 or for rising PSA. In this case, the patient does not have any of the adverse pathologic factors. Final Result: The reviewers determined that the requested testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision DX gene testing for evaluation of the enrollees melanoma. Findings: All three physician reviewers found that there is a lack of definitive data regarding the use of Decision DX gene testing 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. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for magnetic resonance angiogram (MRA) of the brain blood vessels for evaluation of the enrollees recurring brain tumor (craniopharyngioma). Findings:  The physician reviewer found that the standard of care in pediatrics is moving away from using computed tomography angiography due to the evidence that the overall lifetime radiation received by this modality has a very high potential to increase the risk of cancer in later years of life. After reviewing the data, repeated findings appear to suggest that MRA is an appropriate modality to image brain blood vessels, in this patients case. Furthermore, MRA appears to be a better modality for patients requiring repeated follow up because MRA does not expose the patient to iodizing radiation. The records show that MRA has been used to monitor this patient and has been an effective modality in monitoring the progression of his medical condition. One study pointed out, that a child who has an MRA performed every three months for surveillance MRA is a safe and appropriate modality. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric hematology-oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the cellular function assay with stimulation test involving tumor necrosis factor (TNF) antagonists drug level and neutralizing antibody for evaluation of the enrollees Crohns disease. Findings: Two of the three physician reviewers found that Simultaneous measurement of serum infliximab level and infliximab antibody titers prior to administration of regular infliximab dose significantly increases the diagnostic accuracy for the therapeutic decision in patients uncertainly responding to the therapy. According to a study, patients who had poor responses and sub-therapeutic infliximab trough levels had an improved response to dose intensification. Tailoring individual infliximab treatments based on infliximab trough levels is supported in the medical literature and widely used for patients with Crohns disease. Levels are generally checked before increasing the dose or changing frequency and helps to decide if the change in dose or frequency of the drug will make a positive impact on the patients health outcome. Final Result: The reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1 and 3 are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology and are actively practicing. Reviewer 2 is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing (The Myriad MyRisk Hereditary Cancer test  81479) . Findings:  Three physician reviewers found that the MyRisk gene testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based on the documentation submitted for review, in this clinical setting the genetic testing was not indicated to evaluate the patients cancer risk. In sum, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. enrollees risk of cancer. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.