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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested authorization and coverage for whole exome sequencing genetic test. The enrollee has developmental delays and central nervous system anomalies.  Her medical history is significant for hemiparesis, sensorineural hearing loss (SNHL) of the right ear with unrestricted hearing of the left ear, abnormal eye movements, cerebral ventriculomegaly, Dandy-Walker syndrome variant and pineal tumor.  Due to the heterogeneous nature of rare genetic diseases, her physician recommended whole exome sequencing genetic testing indicating results from this genetic test will have a direct impact on treatment and management and will provide prognostic information that will assist in clinical management. Peer-reviewed literature describes the clinical utility of whole exome sequencing (WES) studies; providing meaningful data to use in care planning, diagnosis, and clarification of reproductive risks for the extended family in a timely manner. This diagnostic performed better in this regard than standard methodologies. The procedure can yield new and relevant diagnoses; changing the management of affected children. Traditional methods of evaluating children with neurodevelopmental disorders (NDDs) yield molecular diagnoses in less than fifty percent. In a study, children with NDD who received whole-genome sequencing (WGS) and whole-exome sequencing (WES) resulted in a change in clinical care or impression of the pathophysiology in 49% of newly diagnosed families. The use of exome sequencing can impact the medical care of critically ill infants with genetic disorders. The enrollee is a good candidate for this test because she has developmental delay and brain congenital malformations. This test is recommended for children with developmental delay and/or congenital malformations.  This diagnostic is helpful for patients who have tested negative for genetic disorders, but for whom a high suspicion of genetic disease remains.  This testing is an important patient management tool, as it allows for  identifying causative mutations associated with actionable co-morbidities or by identifying appropriate clinical trials. WES is an accepted standard of care for the member.Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in clinical genetics and one review board certified in pediatric neurology and are actively practicing.  All three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast implants or fat injections to increase breast size. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. The patient underwent a bilateral breast reduction. She reports that her breasts are too small and unequal in size following the procedure. She is 5 feet tall, weighs 160 pounds, and has a BMI of 31.3, with a markedly globular abdomen. Her functional symptoms of back and neck pain with intertrigo have been improved since she underwent breast reduction surgery. There is no documentation of any functional issues related to breast size. Therefore, breast implants or fat injections to increase breast size is not medically necessary. Further, the requested surgery is not being performed to correct or repair an abnormal structure of the body caused by congenital defect, developmental abnormality, trauma, infection, tumor, or disease. The patients photographs show reduced breasts with shape and size within normal range. The breasts are resting on a globular and protuberant abdomen. The patients axillary tissue is within normal limits. Moreover, no functional issues have been documented in relation to the patients breast size. The appearance of the patients breast shape and size are within the range of normal for a female habitus. Since the requested breast augmentation will not improve function or create a more normal appearance, the requested breast implants or fat injections to increase breast size is not reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and are not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollees representative has requested authorization and coverage for physical therapy, occupational therapy and speech therapy. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records do not document that the treating provider has identified objective improvement with the services already provided. The clinical notes do not indicate that the patient is likely to obtain sustained functional benefit from additional treatment.  The physician reviewer found that the patient has a history of anoxic brain damage. The records document significant contractures in all extremities. Medical treatment options were recommended to address his contractures prior to additional therapy. Given the lack of documented improvement from the most recent round of treatment and a lack of clarity as to how further treatment is likely to provide sustained functional benefit, the requested services are not medically indicated. Therefore, physical therapy, occupational therapy and speech therapy are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for a wireless capsule endoscopy (CPT 91110). The American Gastroenterological Association (AGA) and American Society for Gastrointestinal Endoscopy (ASGE) guidelines support wireless capsule endoscopy for investigation of iron-deficiency anemia or gastrointestinal bleeding when esophagogastroduodenoscopy and colonoscopy do not provide an explanation, polyposis syndromes, celiac disease, and Crohns disease (Wang, et al.). The current medical literature supports an indication for wireless capsule endoscope the physician reviewer found that y for the evaluation of patients with gastrointestinal bleeding, Crohns disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies (Enns, et al.). Wireless capsule endoscopy is limited to detection of diseases that result in structural abnormalities that can be identified solely based on appearance. SIBO does not result in any visually apparent changes in the small intestine. In addition, the records do not support suspicion for Crohns disease or other diseases for which wireless capsule endoscopy is an appropriate test. Wireless capsule endoscopy is not a recommended test for the diagnosis of SIBO (Ponziani, et al.). For these reasons, a wireless capsule endoscopy (CPT 91110) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for four Barrx Ablation Procedures that have been performed, and has requested authorization and coverage for the Barrx ablation procedure. Patients with family history of esophageal cancer have a predilection for esophageal cancer themselves. The risk of esophageal cancer in a patient with two first-degree relatives who have esophageal cancer (defined as familial Barretts esophagus) increases markedly, by over ten-fold in some studies. Expert opinion on ablation of non-dysplastic Barretts recommends ablation in patients with family history of esophageal cancer. The American Society of Gastrointestinal Endoscopy considers ablation to be a preferred management option in patients with family history of esophageal cancer. Known precursors to esophageal cancer such as Barretts Esophagus should be addressed when present in a patient with two first-degree relatives with esophageal cancer. In this case, the patient has had three relatives with esophageal cancer. The ablations performed in this case were performed until the visible Barretts esophagus was eradicated, so multiple sessions were appropriate. Accordingly, the four Barrx Ablation Procedures that have been performed, as well as the requested Barrx Ablation Procedure, were, and are, likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue, as well as the requested services, were, and are, likely to be more beneficial than any other available standard treatments for this patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in gastroenterology, 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 Brilinta 90 mg tablets. Treatment guidelines for patients with acute coronary syndrome undergoing stent placement recommend dual antiplatelet therapy for one year. Trials have compared the safety and efficacy of clopidogrel with that of newer antiplatelet therapies, such as Brilinta, and have demonstrated faster onset of action with newer agents and improved thrombotic endpoints. These advantages make new agents more suitable for the treatment of patients with a high thrombotic risk, such as this patient. These newer agents are incorporated in current guidelines. The current medical evidence supports Brilinta in this clinical setting. Therefore, Brilinta 90 mg tablets are medically necessary for the treatment of this patient.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 cardiovascular disease 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Femring Vag Ring 0.1 mg/24 hour with a quantity of two rings per 90 days. The enrollee is experiencing menopausal symptoms of hot flashes, post-menopausal bleeding and vaginal dryness.  She has tried and failed norethindrone, estradiol, and Estrace. Side effects from these medications caused a worsening of her symptoms. She is requesting approval for two rings as this therapy has provided symptom relief. Per enrollee report, the first fem ring alleviated some symptoms but a higher dosage was necessary.  As the fem ring is her only effective option, an additional fem ring is needed to supply the necessary dosage. Guidelines indicate the use of preparations such as the Femring include treatment of moderate to severe vasomotor symptoms and moderate to severe vulvar and vaginal atrophy due to menopause. Labeling information notes the Femring is available in two strengths; 0.05 mg/day, for a total of 12.4 mg of estradiol acetate, and 0.10 mg/day, for a total of 24.8 mg of estradiol acetate. The product is released at the specified daily dosage over three months. Femring has a black box warning about endometrial cancer, breast cancer and an increased risk of cardiovascular disease. This enrollee has a uterus and is therefore at risk for endometrial cancer. Higher doses of estrogen could possibly increase these risks.   There is no approval for the use of two rings. There is no data regarding the effectiveness, safety, side effects and long term risks of this product.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in obstetrics and gynecology and reproductive endocrinology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for referral to a vascular surgeon. This enrollee has prominent varicose veins and is being referred to a vascular surgeon after having tried compression stockings. The medical literature indicates chronic venous disease refers to a wide spectrum of morphologic, such as venous dilation and/or functional abnormalities, such as venous reflux of long duration.  Vein-related problems may or may not be symptomatic and include a wide range of clinical signs that vary from minimal superficial venous dilation to chronic skin changes with ulceration.  Lower-extremity chronic venous disorders encompass an entire spectrum of morphologic and functional abnormalities of the venous system. Symptoms include pain, leg heaviness or aching, swelling, dry skin, tightness, skin irritation, heaviness, muscle cramps, and itching.  Clinical signs include dilated veins, edema, lipodermatosclerosis (a fibrosing dermatitis of the subcutaneous tissue), or ulceration.  The record indicates the enrollee has prominent varicose veins on examination that are inflamed and hurt, despite compression stockings. Therefore, the requested referral to a vascular surgeon is medically necessary to treat the enrollees medical condition. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in vascular 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sclerotherapy. Current Society for Vascular Surgery (SVS) and American Venous Forum (AVF) guidelines recommend compression therapy as the primary treatment to aid healing of venous ulceration. The guidelines also support phlebectomy or sclerotherapy to treat varicose tributariesand suggest foam sclerotherapy as an option for the treatment of the incompetent saphenous vein. A review from medical literature demonstrates that the available clinical trial evidence suggests that endovenous thermal ablation should be preferred to surgery and foam sclerotherapy in the treatment of GSV and small saphenous vein (SSV) incompetence. The prevalence of tributary reflux alone is present in about 10% of patients and most have CEAP 2 and 3 symptoms. Following GSV ablation, persistent non-refluxing branches do not appear to have an adverse impact on clinical outcome one year after successful ablation of the GSV. There is insufficient clinical data to recommend ablation of the non-axial veins. This patient is status post radiofrequency ablation on the left GSV. The records document failure of compression therapy. She currently presents with bilateral symptomatic varicose veins. The left leg residual varicose veins are suitable for injection sclerotherapy. There is evidence to support sclerotherapy in the treatment of accessory recurrent varicose veins following radiofrequency ablation. However, the records do not support treatment with sclerotherapy for the right leg. The current medical literature support endovenous thermal ablation in the treatment of GSV incompetence. Therefore, left leg sclerotherapy is medically necessary for the patients accessory recurrent varicose veins. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in surgery with subspecialty certification in vascular 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for a power assist wheelchair. The enrollee has cerebral palsy and generalized muscle weakness. He is mostly wheelchair-bound, is unable to ambulate functionally and uses an ultra-lightweight manual wheelchair for all mobility activities. The enrollee experiences fatigue when using his wheelchair for long distances, and is often stranded due to his level of fatigue and requires family members to pick him up. His internal medicine specialist has requested authorization for a power assist system for the patient. Added to his current wheelchair, the SmartDrive power assist system would give the patient the ability to get himself home safely and reduce the number of total pushes throughout the day; limiting fatigue. The record indicates the enrollee utilizes a manual wheelchair independently and recently received an ultralight-weight wheelchair.  He is able to independently transfer in and out of his wheelchair and perform effective pressure relief.  He continued to possess pain-free range of motion and strength, allowing him to independently self-propel a manual wheelchair.  He shops independently and is able to perform light daily tasks.  He travels independently; either on public transportation or driving his own vehicle.  The enrollee's manual ultralight-weight customizable wheelchair was approximately two months old and in excellent condition. The medical literature indicates how the utilization of power assistance may be effective in reducing potential risk factors. A power assist wheelchair may be indicated for enrollees who are developing overuse injuries, or for enrollees who lack the upper extremity strength to drive a hand-rim wheelchair.  There is no indication the enrollee has developed overuse injuries or does not have sufficient strength to propel a manual wheelchair.  Medical literature indicates requirements for power mobility devices are described as impairments in mobility-related activities of daily living; such as toileting, feeding, dressing, grooming, bathing and travel to customary locations in the home that cannot be ameliorated by a lesser device.  This enrollee has an ultra-light manual wheelchair, which adequately addresses his mobility needs for mobility-related activities of daily living.  There is the indication in the record the power device is being prescribed not to address mobility-related activities of daily living in the home, but rather to help him when he is out and becomes too tired to return home. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine & rehabilitation 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement the anterior optical coherence tomography (OCT). The anterior segment optical coherence tomography (OCT) used in this patients case was consistent with the recommendations in the current peer-reviewed medical literature. OCT is the standard of care for the evaluation of this patients condition and can provide information critical to treat her disease. In this case, anterior segment OCT was used to measure the patients cornea prior to keratoprosthesis surgery. Alternative modalities would not have provided comparable data and would have placed the patient at an increased risk. Accordingly, the anterior segment OCT was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found anterior OCT was likely to be more beneficial for evaluation of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the anterior OCT 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: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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.