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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic laboratory testing (CPT 81240  coagulation factor II prothrombin; CPT 81241  coagulation factor V Leiden; and CPT 81291  5,10-methylenetetrahydrofolate reductase (MTHFR). This patient experienced preterm contractions at 19 weeks gestation while traveling. She presented to a local provider for evaluation. In addition to routine obstetrics laboratory testing, she underwent testing for inherited thrombophilias. The patient reports that her provider recommended testing given her painful contractions to ensure that her pregnancy did not deteriorate. However, there is a paucity of peer-reviewed medical literature or guidelines supporting a clinical role for the testing performed in patients who present with preterm contractions. According to the American College of Obstetricians and Gynecologists (ACOG), there is a lack of support to establish a causal link between inherited thrombophilias and adverse pregnancy outcomes. ACOG noted that screening for antiphospholipid antibodies might be appropriate in patients experiencing fetal loss, defined as three spontaneous losses. This patient did not meet the definition of recurrent miscarriage since this is her first pregnancy. In addition, the records do not report concern for inherited thrombophilia based on recurrent, unexplained late fetal loss associated with evidence of placental ischemia and maternal vessel thrombosis. Moreover, the available data does not support screening for presence of the MTHFR variant in asymptomatic patients. An extensive literature review has shown a lack of association of heterozygosity of the MTHFR mutation and miscarriage. All told, the genetic laboratory testing (CPT 81240  coagulation factor II prothrombin; CPT 81241  coagulation factor V Leiden; and CPT 81291  MTHFR) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the genetic laboratory testing (CPT 81240  coagulation factor II prothrombin; CPT 81241  coagulation factor V Leiden; and CPT 81291  MTHFR) 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 reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the continuation of physical therapy and continuation of occupational therapy.The submitted documentation does not support that the requested services are medically necessary. The literature on rehabilitation and physical exercise for patients with Guillain-Barre shows a positive association with improved health outcomes with exercise in this population, however the research is limited. The literature on the optimal type of rehabilitation and duration as well as best rehabilitation interventions for Guillain-Barre patients is scant and additional studies with higher methodological quality are needed to validate these findings and evaluate the optimal rehabilitation treatment plan. In this case, the patient's current functional level does not require the continuation of physical therapy and occupational therapy services. The patient has had extensive therapy and his functional level has reached a plateau and does not require continuation of the physical therapy and occupational therapy services that were previously received at the skilled level of care. Accordingly, the requested continuation of physical therapy and continuation of occupational therapy are not medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested services are not medically necessary for the patients condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation, with subspecialty certification in neuromuscular medicine, 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 HP Acthar Gel 80 units subcutaneously twice a week. The U.S. Food and Drug Administration approves the use of Acthar Gel for rheumatic disorders and diseases, such as systemic lupus erythematosus (SLE) flares. In a study of the use of Acthar Gel in SLE treatment, Li and colleagues concluded that their study suggests a role for Acthar Gel as an alternative to corticosteroids in the treatment of SLE. Acthar Gel appears to be safe and well-tolerated after six months of treatment, with a significant reduction in disease activity. In a study of 44 patients with nephrotic syndrome (NS) who failed to respond to standard therapy, Studies found that, Acthar Gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. In this case, the patient has failed standard therapy and is experiencing complications of chronic corticosteroid use. The records demonstrate that the patients care has been complicated by recurrent infections, including a significant infection resulting in a four-month hospital stay, and bilateral avascular necrosis of the hips. Therefore, HP Acthar Gel 80 units subcutaneously twice a week is 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 rheumatology 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 Tibsovo 250 mg two (2) tablets daily. The U.S. Food and Drug Administration indicates that Tibsovo, an isocitrate dehydrogenase-1 (IDH1) inhibitor, is appropriate for the treatment of advanced acute myeloid leukemia. While researchersfound that ivosidenib was well-tolerated with no dose-limiting toxicities in a phase I trial of 66 patients with advanced IDH1-mutant astrocytoma, oligodendroglioma, or glioblastoma, the National Comprehensive Cancer Network recommends several other treatment options. In this case, the patient has only been treated with surgery, and the documentation does not reflect other attempted therapies or treatment options, including possible resection, radiation, temozolomide, Lomustine or carmustine, and platinum-based regimens. Given the patients diagnosis and other available treatment options, the use of ivosidenib is not medically indicated. Therefore, Tibsovo 250 mg two (2) tablets daily are  not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nutropin AQ Nuspin. In this case, the patient was on growth hormone therapy for approximately two years. His growth velocity was reported as 7.3 cm/year and 7.4 cm/year over two visits while he was receiving therapy. Visit documentation shows that once he was off growth hormone therapy, he still showed a normal growth velocity of 6.3 cm/year. The patients height has never been more than 2.25 standard deviations from the mean. The patients predicted adult height falls within the normal range for male in the United States and is greater than his mid-parental height of 62.1 inches. Therefore, Nutropin AQ Nuspin is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 13-month-old male who has been diagnosed with atopic dermatitis. The patient was noted to have intermittent itching. Physical examination findings included a healing right cheek excoriation and faint erythematous scaly thin plaques. A xerotic patch was noted on the patients left leg. The patient was noted to have a history of eczema and has been treated with Elidel topical cream, fluocinolone, hydrocortisone, mupirocin, and triamcinolone. The patients parent has requested authorization and coverage for tacrolimus (Protopic) 0.03% ointment. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether tacrolimus (Protopic) 0.03% ointment is medically necessary for the treatment of the patients medical condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions. Eichenfield and colleagues reported, Tacrolimus 0.03% ointment and pimecrolimus cream are indicated for use in individuals age two years and older, while tacrolimus 0.1% strength is only approved in those over age 15 years. However, evidence from clinical trials supports the safe and effective use of topical tacrolimus 0.03% and pimecrolimus in children less than 2 years of age, including in infants. In this case, the patient is a 13-month-old with atopic dermatitis and a history of eczema. Per the records, he has tried multiple medications. The medical evidence supports the requested medication in this clinical setting. The use of tacrolimus will have a steroid sparing effect that will help to decrease long-term unwanted effects of steroids, including striae and thinning of the skin as well as potential systemic effects, including stunted growth.  In this patients case, the requested medication is medically necessary to prevent disease, disability, and other health conditions or their progression. Therefore, tacrolimus (Protopic) 0.03% ointment is 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 dermatology 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: This is a male with a history of hypertension, glucose intolerance, and sleep apnea. He was admitted to the hospital and diagnosed with new onset of congestive heart failure (CHF) New York Heart Association (NYHA) class III, secondary to ischemia (reduced blood flow) and coronary artery calcifications, with a left ventricle ejection fraction (EF) of 25-30% demonstrated by the echocardiogram (a normal EF is considered to be 55% or higher). He underwent coronary balloon angioplasty and stent placement. The patient was to continue on aspirin and Plavix for at least 12-18 months. In a follow-up visit, the cardiologist noted that the patient was improved, with findings of CHF now in the NYHA class II. He was to continue with medications (Lasix, Lisinopril, Coreg, aspirin, Plavix, and atorvastatin), undergo an echocardiogram in one month, and follow a prescribed diet. At issue was whether the LifeVest Wearable Cardioverter Defibrillator provided by Zoll Services LLC from December 26, 2019 through February 5, 2020, was likely to be more beneficial than any available standard therapy in the treatment of this patients condition. Two reviewers noted that the use of the LifeVest Wearable Cardioverter Defibrillator (WCD), in addition to optimal medical management such as medication and diet, is supported in peer-reviewed literature for primary prevention of sudden cardiac death due to a ventricular arrhythmia in patients with ischemic cardiomyopathy, reduced cardiac EF and recent revascularization. The LifeVest has final approval from appropriate regulatory bodies for treatment of this patients condition. It is appropriate after treatment of ischemic heart disease with recent revascularization (coronary artery stenting). Final Result: Two of the three reviewers determined that the requested services were likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewers are board certified in cardiology/cardiovascular disease 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 similar medical condition
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for embryo genetic testing (CPT codes 99000, 81228, and 88299). Fragile X premutation carrier screening is recommended for patients with a family history of fragile X-related disorders or intellectual disability suggestive of fragile X syndrome, and who are considering pregnancy or are currently pregnant. The American College of Obstetricians and Gynecologists (ACOG) identified that patients with intermediate results and carriers of a fragile X premutation or full mutation should be provided follow-up genetic counseling to discuss the risk to their offspring of inheriting an expanded full-mutation fragile X allele and to discuss fragile X-associated disorders. Carrier screening and counseling performed before pregnancy enables couples to learn about their reproductive risk and consider the most complete range of reproductive options, including whether or not to become pregnant and whether to use advanced reproductive technologies such as preimplantation genetic diagnosis or use of donor gametes. This patient underwent PGTA based on her abnormal screening, which demonstrated that she is a carrier for Fragile X syndrome. Given these findings, the embryo genetic testing (CPT codes 99000, 81228, and 88299) was 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 embryo genetic testing (CPT codes 99000, 81228, and 88299) was 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 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 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 with subspecialty certification in pediatrics 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 patient has requested authorization and coverage for facial feminization surgeries including CPT 30410  rhytidectomy, cheek, chin and neck; CPT 14060  adjacent tissue transfer, eyelids, nose, ears and/or tips (10 sq cm or less); CPT 14021  adjacent tissue transfer, scalp, arms, legs (10.1-30 sq cm); CPT 21139  reduction forehead, contouring and setback of anterior frontal; CPT 21121  genioplasty, sliding osteotomy; CPT 67900 x 2  brow lift; CPT 15773  grafting of autologous fat by liposuction (25 cc or less); CPT 15774 x 4  grafting of autologous fat by liposuction (each additional 25 cc). Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) supports facial feminization surgery to help alleviate the distress associated with an incongruent physical appearance and gender identity. WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. The guidelines further report that, these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. This patient presents with gender dysphoria as noted by her providers in their letters written in support of facial feminization surgery. The patient transitioned to non-binary and was started hormone therapy in June 2018. The patients providers have recommended facial feminization surgery to address the patients gender dysphoria. Based on the WPATH SOC, the requested facial feminization surgeries including CPT 30410  rhytidectomy, cheek, chin and neck; CPT 14060  adjacent tissue transfer, eyelids, nose, ears and/or tips (10 sq cm or less); CPT 14021  adjacent tissue transfer, scalp, arms, legs (10.1-30 sq cm); CPT 21139  reduction forehead, contouring and setback of anterior frontal; CPT 21121  genioplasty, sliding osteotomy; CPT 67900 x 2  brow lift; CPT 15773  grafting of autologous fat by liposuction (25 cc or less); CPT 15774 x 4  grafting of autologous fat by liposuction (each additional 25 cc) are medically necessary for treatment of this patient. 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for surgery performed in Syria. This patient was diagnosed with renal cancer by computed tomography scan of the abdomen, which revealed a 2 cm enhancing lesion in upper pole of the left kidney. The patient did not have immediate surgery and went to Syria on vacation. While in Syria her father took her to several physicians and it was determined that surgery was needed for the kidney lesion. She underwent a left partial nephrectomy via 11th rib incision. At issue is whether the surgery performed in Syria was considered emergency medical services as defined in California Health and Safety Code section 1317.1. All medical records provided indicate that this was elective excision of a small (approximately 2 cm) solid left renal lesion. There was no urgent or emergent indication for surgery on this renal lesion, such as bleeding, intractable pain, or paraneoplastic syndrome. It was a small renal cell carcinoma and it most cases surgical removal is recommended to eradicate the tumor, confirm diagnosis, prevent possible future tumor growth or possible spread to other areas of the body. There was no urgent or emergent medical situation in this case that required that the patient undergo left partial nephrectomy overseas on 9/1/18. Final Result: The reviewer determined that the surgery performed in Syria on 9/1/18 was not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in urology 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.