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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator (Inspire procedure). Findings:  The physician reviewer found that the Inspire hypoglossal nerve stimulator is U.S. Food and Drug Administration (FDA) approved, and recognized by the American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) and the International Sleep Surgery Society (ISSS). With regard to efficacy, the STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of symptoms in patients with OSA (Woodson, et al). The authors noted that upper airway stimulation addresses the twin goals of improving anatomic and neuromuscular pathology. Further, the authors concluded that hypoglossal nerve stimulator can benefit patients with OSA who have failed CPAP, have nonconcentric airway collapse, an AHI between 20 and 50, and a body mass index (BMI) of less than 32 kg/m2. This patient is intolerant to CPAP and has a BMI of 31 kg/m2, an AHI of 45, and nonconcentric airway collapse. Thus, the implantation of hypoglossal nerve stimulator (Inspire procedure) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the implantation of hypoglossal nerve stimulator (Inspire procedure) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the implantation of hypoglossal nerve stimulator (Inspire procedure) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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 Synvisc-One injections to both knees. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As noted by Maheu and colleagues, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, and a reduction in use of concomitant analgesia by up to 50%. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee pain due to osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, the requested injections to both knees are medically necessary to treat the patients medical condition.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 15-year-old male enrollee has authorization and coverage for testosterone cypionate 200 mg/mL. Findings:  The physician reviewer found that masculinizing therapy for female to male transgender patients consists primarily of testosterone therapy. The Endocrine Society has recognized that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years. The Endocrine Society recommends treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. This patient meets the criteria for continued treatment with testosterone therapy. The records document the patient has been living as an authentic male for more than nine years and has been treated for a diagnosis of gender dysphoria for seven years. The patient started puberty suppression in 2013 and has been treated with testosterone for three years. The provider reports the patient has demonstrated a greatly improved quality of life since starting treatment with testosterone therapy. Given these findings, the requested testosterone cypionate 200 mg/mL is medically necessary for treatment of this patients gender dysphoria. 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 endocrinology, diabetes and metabolism 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

Findings:  The physician reviewer found that an enrollee with chronic Hepatitis C, genotype 1 (1a or 1b) and F1-F2 fibrosis has requested authorization and coverage for Mavyret 100-40 mg tablets for eight (8) weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees condition. According to the most recent 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 limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Mavyret 100/40 mg three tablets daily for 8 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic Hepatitis C genotype 1 regardless of fibrosis stage. The ENDURANCE-1 trial showed that only 8 weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mayvret is supported as medically necessary for 8 weeks for the treatment of this patients Hepatitis C infection. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Genetic Testing. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision but they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. Overall, the data on the DecisionDx-Melanoma does not support its use as part of routine analysis in this clinical setting. Accordingly, the DecisionDx-Melanoma Genetic Testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Genetic Testing 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 DecisionDx-Melanoma Genetic Testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing (CPT 81201, 81211, 8120, 81235, 81270, 8127, 81292, 81295, 81298, 81321) provided on 10/11/16.  Findings:  The physician reviewer found that recent literature explains that there is a risk of Richters transformation where the CLL may progress to more aggressive large cell lymphoma. Many combinations of chemotherapies and newer agents have been shown to have a response in CLL but none have clearly demonstrated an improvement in overall survival, according to the CLL Trialists Collaborative Group. The patient has exhibited potential resistance to therapy and mutational analysis was indicated. The Foundation Heme test analyzes over 400 oncogenes and tumor suppressor genes for mutations that may be amenable to targeted therapies. This is particularly important for those that have progressed on standard regimens. Molecular genetics can help guide therapy decision making, including evaluation for clinical trial. The use of molecular profiling such as with FoundationOne testing is likely to be more beneficial than any available standard therapy.  Final Result: Two of the three reviewers determined that the services at issue were 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/QualificationsAll three reviewers are board certified 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: A male enrollee has requested reimbursement for hospitalization services provided at Rancho Los Amigos National Rehabilitation Center. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees pressure ulcer. Findings: In this case, the patient had complex wound care needs. He had already undergone a girdlestone hip procedure and developed a stage IV pressure ulcer, which required a diverting colostomy with a recent right gluteal flap. He had comorbid conditions that would be expected to impair his ability to adequately perform pressure reliefs or perform skin checks. He had medical and skilled nursing needs requiring acute level care. He required the experience and expertise of trained clinicians to manage the patients complex wounds and to the begin sitting protocol that was requested, as well as to assist in directing his care. Given the extensive surgical procedures previously performed, there were few remaining surgical options; and if he succeeded with the acute level of care requested, he would be able to avoid further surgeries. He had already undergone a gluteal flap procedure, which limited his remaining surgical options. He ultimately had an additional surgery, which supports that care at a lower level could not have been effectively provided or met his medical, surgical, and rehabilitation needs. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 physical medicine and 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 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 MRI of the spine. Medical literautre has established Appropriateness Criteria for several clinical presentations. Medical literature has listed appropriate approaches to both low back pain and chronic neck pain. Medical literature has not presented criteria for chronic thoracic pain, the same considerations apply to the mid-back as apply to the neck and the lower back. The medical literatures Chronic Neck Pain criteria for patients who are NOT in the clinical setting of trauma, pre-existing malignancy, or infection, most closely resembles the patients clinical presentation. This medical criteria recommends plain x-rays as a first line study, and specifically states that MRI of the cervical spine is generally not appropriate. Under this guideline, MRI is not appropriate unless a patient has specific neurological signs or symptoms. Similarly, the medical literature has established appropriateness guidelines for low back pain, and, as with cervical spine pain, MRI is not routinely recommended unless there are additional signs or symptoms. In this case, the patients submitted records do not reflect that they have significant localizing symptoms other than pain. The patient has no neuropathies, strength is reported to be good, and the physical exam was essentially negative. Under these circumstances, it may be appropriate that the patient be referred to a specialist to better evaluate the cause for pain, and an intensive conservative approach to their therapy is first warranted. It is possible that the patient may ultimately need MRI, but that should be done after a thorough evaluation and a conservative trial is attempted. Therefore, MRI of the spine is not medically necessary for the treatment of the patients medical condition at this time.Final Result: The reviewer determined that the requested service 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 10-year-old male enrollee has requested authorization and coverage for Nutropin. Applying the American Association of Clinical Endocrinologists (AACE) guidelines for clinical practice for growth hormone use and generally accepted criteria set by the U.S. Food and Drug Administration (FDA) for treatment of short stature with GH therapy, the requested GH therapy is medically necessary. Although this patients pre-treatment height was not below the third percentile, he had a bone age that was ahead of his chronological age, resulting in a poor adult height prediction of 62 inches with the Bayley-Pinneau method. This height prediction is more than two standard deviations below the genetic target height and below the mean U.S. adult male height. Thus, continuation of Nutropin GH therapy is medically necessary for treatment of this patients medical condition. 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 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: A transgender female enrollee has requested authorization and coverage for facial feminization surgery. Studies show that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. Studies further noted that other surgeries for assisting in body feminization includerhinoplastyfacial bone reduction, face-lift, and blepharoplasty. This patient has a masculine bone structure that is causing gender dysphoria and social dysfunction. A psychological evaluation indicates that patient is depressed from the presence of masculine facial features. The patient has been living as a woman since age 23 and receiving feminizing hormone treatment since that time. The patient is committed to feminine transformation as evidenced by an orchiectomy. The patient meets the criteria for gender dysphoria and indication for facial feminization surgery based upon clinical documentation of persistent gender dysphoria related to masculine facial features associated with social dysfunction. The requested facial feminization surgery is medically necessary to help alleviate the patients gender dysphoria and related distress. Given these findings, the requested facial feminization surgery is supported as medically necessary for treatment of this patients gender dysphoria. 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 with expertise in transgender health 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: An enrollee has requested reimbursement for facial feminization surgeries. The enrollee has also requested authorization and coverage for additional facial feminization surgery. Gender dysphoria refers to distress that is caused by a discrepancy between a persons gender identity and that persons sex assigned at birth. This often results in depression and anxiety. Treatment for gender dysphoria aims to minimize dysphoria and help patients attain their sought-after gender role. Studies show that the essential purpose of transition-related treatments such as facial feminization surgery is to therapeutically treat gender dysphoria, not to improve a persons appearance. Studies for sex reassignment surgeries and the treatment of gender dysphoria, and concluded that, Gender reassignment is the only treatment for gender dysphoria that has shown significant benefits in numerous research trials and meta-analyses over the past half century. Studies show that, Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS [facial feminization surgery], GRS [gender reassignment surgery], or both) are associated with improved mental health-related quality of life. Studies show that facial feminization surgery does not aim to rejuvenate the face, but rather, it helps transgender women in passing as a female and integrating into everyday society. Accordingly, the submitted documentation demonstrates that the patient has had gender dysphoria that relates to male facial features and that has not been alleviated by other treatments. There is sufficient scientific literature demonstrating that facial feminization surgery is effective in relieving gender dysphoria in patients such as this patient. Therefore, the facial feminization surgeries that the patient received were medically necessary to treat the patients medical condition, and the requested additional facial feminization surgery is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that both the services in issue and 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.