Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a panniculectomy.At issue is whether the requested panniculectomy is medically necessary to treat the patients medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?According to the American Society of Plastic Surgeons, a panniculectomy should be considered a reconstructive procedure when performed to correct or relieve structural defects of the abdominal wall, improve skin health within the fold beneath the pannus, and/or help improve chronic low back pain due to functional incompetence of the anterior abdominal wall. Moreover, researchers state that panniculectomies have been shown to be of benefit for the quality of life of patients. In this case, the patients pannus hangs below the pubis and has caused intertrigo. The patient has been prescribed steroid creams and antifungal medications. There is adequate documentation in the medical records indicating that these rashes and fungal infections are persistent despite appropriate hygiene as well as the antifungal and steroid creams. Therefore, the requested panniculectomy is medically necessary to treat the patients medical condition.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; (2) to create a normal appearance, to the extent possible. The patients condition is an abnormal structure of the body as a result of massive weight loss after a medically necessary procedure. The pannus has resulted in chronic fungal infections. The requested surgery will eliminate the pannus and help avoid fungal infections. The surgery will provide more than a minimal benefit, as it should eliminate the rashes, bleeding and burning sensation. Additionally, the procedure is expected to restore function. Therefore, the requested panniculectomy is reconstructive in nature. Final Result: The reviewer determined that the requested service is 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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for scar revision surgery (CPT 13120  repair, complex, scalp, arms, and/or legs).Oosterwijk and colleagues state, Scar contractures are the pathological outcome of excessive scarring and ongoing contraction...When contracting scar tissue is across or adjacent to a joint, this may result in loss of range of motion (ROM) in one or more movement directions of that joint. This can subsequently cause problems in the performance of activities concerning daily living (ADL), school, work, sports, and leisure time and, therefore, poses a threat to quality of life in the long term. Additionally, Eilers and colleagues state, Surgical scars are best treated with a combination approach to address various features of the scarFirst, the clinician should assess if there is significant tension or webbing associated with the surgical scar. In this case, surgical revision of the scar is often warranted. In this case, the patient underwent excision of an intramuscular lipoma of her deltoid muscle. Photograph shows that the scar is flat, moderately widened, and well-healed. There is no evidence of tension, webbing, or scar hypertrophy. Skin healing is asymptomatic, with no pain, wound healing, or functional issues noted. Therefore, scar revision surgery is not medically necessary to treat the patients medical condition.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; (2) to create a normal appearance, to the extent possible. In this case, the patients scar shows normal healing. A scar showing normal healing is not an abnormal structure of the body. There are no functional issues. The appearance is consistent with normal healing following a surgical procedure. The California reconstructive surgery statute does not apply to this patient. Therefore, the requested scar revision surgery is not reconstructive in nature.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition and not reconstructive in nature. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gamunex-C intravenous immunoglobulin (IVIG). The records provided for review document that this patient has Sjogrens syndrome per biopsy and symptoms of tachycardia, dizziness, and lightheadedness consistent with postural orthostatic tachycardia syndrome (POTS) (Blitshteyn). The patients symptoms were not substantially improved with metoprolol or diltiazem. The patients provider has recommended treatment with Gamunex-C IVIG. There are case studies in the peer-reviewed medical literature that demonstrate significant improvement in patients with POTS when treated with IVIG replacement therapy (Rodriguez, et al.). In addition, there is growing evidence to support that this type of dysautonomia may be immune mediated. Therefore, it is appropriate to provide a trial of IVIG for this patient and reassess in a few months to assess the degree of improvement in symptoms and to determine whether IVIG should be continued. For these reasons, the requested Gamunex-C IVIG is medically necessary for 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 subspecialty certification in allergy and immunology 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 reimbursement for genomic sequencing (CPT 81422). This patients records document a history of hypoglycemia, threatened early pregnancy, and urinary tract infection during pregnancy. The patient underwent evaluation with genomic sequencing with the Panorama Prenatal Panel Plus and Panorama Extended Panel. Expanded carrier screening panels with microdeletion testing are not supported for routine work-up of all pregnancies. Given the multitude of conditions that can be included in expanded carrier screening panels, the disorders selected for inclusion should have a carrier frequency of 1 in 100 or greater, a well-defined phenotype, a detrimental effect on quality of life, cause cognitive or physical impairment, require surgical or medical intervention, or have an onset early in life. Additionally, screened conditions should be able to be diagnosed prenatally and may afford opportunities for antenatal intervention to improve perinatal outcomes, changes to delivery management to optimize newborn and infant outcomes, and education of the parents about special care needs after birth. Fetal aneuploidy testing consisting of Trisomy 21, 18, 13 analysis is considered the standard of care. However, carrier screening panels should not include conditions primarily associated with a disease of adult onset. Per the American College of Obstetricians and Gynecologists (ACOG), testing for microdeletions have not been clinically validated. Furthermore, expanded carrier screening panels do not replace previous risk-based screening recommendations. All told, the genomic sequencing (CPT 81422) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Findings:  Two of the three physician reviewers found the genomic sequencing (CPT 81422) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   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: Physician reviewer 1 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology 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: The patients parent has requested authorization and coverage for Trio whole exome sequencing (CPT 81415 and 81416 x 2). Thevenon and colleagues report that clinical whole exome sequencing in individuals with undiagnosed and severe forms of intellectual disability and epileptic encephalopathy may have clinical utility in a patient population that frequently undergo multiple clinical evaluations and low-yield laboratory tests often referred to as a diagnostic odyssey. Nolan and Carlson note that in a review of 53 patients, whole exome sequencing improved the presumptive diagnostic rate in the patient cohort from 25% to 48% and that clinical implications included family planning, medication selection, and systemic investigation. The authors concluded that compared to current second tier testing, whole exome sequencing can result in lower long-term charges and more timely diagnosis. Wise and colleagues report that genomic medicine is being used to obtain molecular diagnoses for patients with previously undiagnosed diseases in prenatal, pediatric, and adult clinical settings, while Kuperberg and colleagues concluded that whole exome sequencing is useful in obtaining a high detection rate for previously undiagnosed disorders and that use of this technique could affect diagnosis, treatment, and prognostics for both patients and relatives. Given its likelihood of yielding a prompt, definitive diagnosis that would guide in the treatment of this patient, the requested service is medically indicated. Therefore, Trio whole exome sequencing (CPT 81415 and 81416 x 2) is medically necessary to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; and to correct or ameliorate any physical or behavioral conditions.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 neurology with special certification in child neurology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right shoulder. due to a multiplicity of potential etiologies, diagnosis of shoulder impingement syndrome is established by a history and physical examination and may be confirmed with x-rays, ultrasonography, and MRI. The authors further note that while initial treatment is conservative, if symptoms persist, decompressive surgery may be necessary, and that a correct etiologic diagnosis and choice of treatment are essential for a good outcome. In this case, the patient reported right shoulder pain that had been present for approximately four months that was not responsive to conservative measures. The provider diagnosed impingement syndrome and recommended an MRI of the shoulder. In this clinical setting, given that the patients pain has lasted over four months and is unresponsive to conservative treatment, and as x-rays did not show a reason for the pain, confirmation of an accurate diagnosis by an MRI is indicated. Therefore, an MRI of the right shoulder is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic 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:  An enrollee has requested authorization and coverage for a laparoscopically assisted vaginal hysterectomy with salpingo-oophorectomy.Laparoscopic-assisted vaginal hysterectomy is considered definitive treatment for abnormal uterine bleeding and potentially may alleviate symptoms of pelvic pain. That said, hysterectomy is not the first-line treatment for these chief complaints in the setting of normal uterine pathology without an obvious source of pain. Typically, providers will consider performing a hysterectomy when there is a predominant uterine pain component by history and/or examination and the patient has exhausted a large number of other multimodal treatments. In this case, pelvic congestion syndrome is seen on imaging via ultrasound, however, it is not a definitive cause of her pain and hysterectomy is not the first-line treatment for it. The clinical documentation in this case is limited.  There is no description of her bleeding or her pain. The extent of these symptoms, the impact they have on her life, why she is choosing hysterectomy over a less invasive option is also not addressed. Additionally, a hysterectomy may not relieve her pain, may only partially relieve her pain, and, in some cases, can worsen pain or cause a new pain that she did not previously experience. Therefore, a laparoscopically assisted vaginal hysterectomy with salpingo-oophorectomy is not medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 obstetrics and gynecology 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 patient has requested authorization and coverage for a lumbar spine magnetic resonance imaging (MRI). Findings:  The physician reviewer found that diagnostic imaging may be indicated for patients with low back pain only if severe progressive neurologic deficits or signs or symptoms suggest a serious or specific underlying condition, and that in other patients, evidence indicates that routine imaging is not associated with clinically meaningful benefits but can lead to harms. The American College of Radiology (ACR) appropriateness criteria note that for acute, subacute, or chronic low back pain, with or without radiculopathy, an MRI of the lumbar spine is usually not appropriate without red flags or prior management; however, the guidelines note that an MRI of the lumbar spine may be appropriate following six weeks of optimal medical management with persistent or progressive symptoms. In this case, the patient was treated for acute onset of left-sided low back pain with left-sided sciatica. While she was treated with medication management and one chiropractic session, the submitted records do not show trial and failure of recent and reasonable conservative care measures. Given that imaging is not indicated in the absence of fully documented severe progressive neurologic impairments without trial and failure of optimal medical management, the requested service is not medically indicated. Therefore, a lumbar spine MRI is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for intraoperative radiation therapy.Findings:  The physician reviewer found that Accelerated partial breast irradiation (APBI) is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria. According to Vaidya and colleagues, this patient meets ABPI criteria set by the American Society of Breast Surgeons with an age older than 45 and tumor less than three centimeters. According to Shaitelman and colleagues, APBI may be delivered using external beam radiation therapy, brachytherapy, or intraoperative radiation therapy. According to the study by Vaidya and colleagues, phase 3 randomized data of over 3,400 patients supported APBI delivered using intraoperative radiation therapy. Toxicity and quality of life may also be slightly improved with intraoperative radiation therapy. While one could argue that follow-up longer than four years is needed, the peak of local recurrence in the study by Vaidya occurred at three years, which is on par with other early breast cancer trials. Therefore, intraoperative radiation therapy is likely to be more beneficial for treatment of the patients condition than any available standard therapy. Findings: Two out of three physician reviewers found that intraoperative radiation therapy is likely to be more beneficial for you than any available standard therapy .Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in radiation 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 Euflexxa injections for the left knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the options are clearly limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, Euflexxa injections for the left knee are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 orthopedic 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.