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 Dexcom G5 continuous glucose monitor. Continuous glucose monitoring systems (CGMS), including real-time systems, have U.S. Food and Drug Administration (FDA) approval. They are not the subject of Phase I-III clinical trials. The peer reviewed literature supports the long-term use of CGMS in adult patients. The ADA position statement on standards of medical care in diabetes states, Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower A1C in selected adults with type 1 diabetes. In addition the peer reviewed literature supports the use of long-term CGMS in patients with type 1 diabetes with hypoglycemia unawareness and episodes of hypoglycemia. There is evidence that real-time CGMS with an alarm function detects hypoglycemia, leads to an improvement in glycemic excursion, leads to a reduction in duration of hypoglycemia, and prevents hypoglycemic reactions in adult patients with type 1 diabetes. The ADA considers this to have a level of evidence of A which is Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered. This is based on a large scale trials published in the New England Journal of Medicine that showed that CGMS is effective in reducing HbA1c in adults with type 1 diabetes over a 6 month period. Furthermore, data from a meta-analysis of multiple clinical trials have shown benefits of CGMS in avoiding hypoglycemia in patients with Type 1 Diabetes. In this case, a CGMS device has potential benefits for the patient, as the patient has Type 1 diabetes, is on an intensive insulin regimen with sub-optimal glycemic control, has a history of hypoglycemic unawareness, and has nocturnal hyperglycemia. Under these circumstances, a Dexcom G5 continuous glucose monitor is medically necessary for 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 internal medicine, with subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing (CPT code 82542, column chromatography/mass spectrometry). The submitted documentation fails to demonstrate the superior efficacy of the services at issue. The test ordered is not a part of the diagnostic strategy or monitoring for the treatment of Lyme based on current guidelines. The diagnosis of Lyme disease is based on screening antibody testing and Western blot testing. The medical evidence does not support the services at issue in this clinical setting. Therefore, the superior effectiveness of laboratory testing (CPT code 82542, column chromatography/mass spectrometry) has not been established. Findings:  Three physician reviewers found 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.Final Result: The reviewers determined that the requested medication is 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 and 2 are board certified in internal medicine with sub-specialty certification in infectious disease and are actively practicing. Physician reviewer 3 is board certified in internal medicine. 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: The parent of an enrollee has requested authorization and coverage for additional physical therapy services. The Official Disability Guidelines (ODG) recommend physical therapy for patients with scoliosis (curvature of the spine) for 12 visits. ODG supports active therapy and not extensive use of passive modalities. ODG further states that the most effective strategy may be delivering individually designed exercise programs in a supervised format (for example, home exercises with regular therapist follow-up), encouraging adherence to achieve high dosage, and stretching and muscle-strengthening exercises seem to be the most effective types of exercises for treating chronic low back pain. Peer-reviewed literature also supports exercise and bracing for non-operative treatment of adult idiopathic scoliosis. Here, the patient presents with back pain due to his underlying scoliosis. He has completed 12 recent visits of physical therapy with elimination of pain and resumption of full activity. The patient reportedly met all physical therapy goals and had been instructed in an independent home exercise program. There is no rationale presented to support the medical necessity of additional physical therapy at this time. There is no current documentation of a specific functional deficit or functional treatment goal to be addressed by additional supervised physical therapy over continuation of his independent home exercise program. Therefore, the request for additional physical therapy services are not medical necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 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: A transgender female enrollee has requested authorization and coverage for facial feminization surgery. Studies indicate that facial feminization surgery is medically necessary for the treatment of gender dysphoria in some transgendered individuals. In terms of patient selection, the studies  note 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. The studies recognizes additional surgeries to promote body feminization may include rhinoplastyfacial bone reduction, face-lift, and blepharoplasty. In this case, the patient has been living as a woman for more than 20 years. The patient has been on hormone therapy since she was 14. She had breast augmentation and silicone injections in her hips. The patient continues to suffer from anxiety and distress secondary to gender dysphoria. Facial feminization surgery is a reasonable and necessary next step in the ongoing treatment of this patients gender dysphoria, and is wholly consistent with the recommendations.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 psychiatry, specializes in treating patients with gender dysphoria 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

enrollee has requested reimbursement for liposuction breast reduction. Per the World Professional Association on Transgender Healths (WPATHs) current Standard of Care, creation of a male chest surgery is appropriate for female-to-male transgender patients with persistent, well-documented gender dysphoria who have the capacity to make a fully-informed decision and to consent for treatment. The patient must be the age of majority in the country/state where the procedure will be performed. If the patient has other significant medical or mental health concerns, then they must be well controlled.  Per California Family Code Section 6500, a person reaches the age of majority when he or she turns 18 years of age.Here, this female-to-male transgender patient was at the age of majority (18 years) at the time of the procedure. There is no evidence suggesting that this patient lacked the capacity to make a fully-informed decision regarding the procedure. Letters from the patients mental health provider and endocrinologist confirm the patients diagnosis of gender dysphoria and readiness for the procedure in question. There is no evidence suggesting the presence of other, uncontrolled medical or mental health concerns. WPATH criteria for creation of a male chest in a female-to-male transgender patient have been met. The fact that this patient elected to have the less-invasive liposuction procedure in lieu of a mastectomy should have no bearing on whether the procedure was necessary for treatment of the patients gender dysphoria.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement, authorization and coverage for residential treatment services. The submitted documentation supports the medical necessity of the patients residential treatment services provided and going forward. American Psychiatric Association practice guidelines for substance use disorders recommend that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use. To qualify for residential treatment, patients must also lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. While the purpose of detoxification is to make the patient psychically stable and safe, rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce risk of relapse. In this case, medical records reflect that the patient has had multiple relapses and has recurrent depression. The patient has exhibited violent and angry behavior toward partners and family members. Furthermore, records reflect a recent overdose. The patient is therefore documented to be at high risk for relapse. Under these circumstances, residential treatment services are in accordance with generally accepted standards of medical practice and are clinically appropriate for the patient's medical condition. Accordingly, all of the residential treatment services provided and going forward, were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services in issue and ongoing services were medically necessary for treatment of the patients medical condition. Therefore, the patient should be reimbursed for the services in issue, and 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Inspire hypoglossal nerve stimulation therapy. Findings: Two of the three physician reviewers found that Inspire hypoglossal nerve stimulation therapy is indicated under these circumstances. After decades of trials demonstrating the benefits of hypoglossal nerve stimulation in animal and human subjects, the 3, 4 and 5 year results of a large multicenter, prospective trial were published in 2016, 2017 and 2018. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea (OSA). This trial has demonstrated that the hypoglossal nerve stimulator is safe and effective in a small subset of patients with OSA who have failed continuous positive airway pressure (CPAP) therapy, have nonconcentric airway collapse, an apnea hypopnea index (AHI) between 20 and 50, and a body mass index (BMI) less than 32. Additionally, a recent study has demonstrated effective outcomes in patients with higher BMI (up to 35) and a broader AHI range (between 15 and 65). Hypoglossal nerve stimulation is FDA approved, and it is recognized by the American Academy of Otolaryngology Head and Neck Surgery as well as by the International Sleep Surgery Society. In this case, the patient meets the criteria that have been established in the medical literature. The patient has failed CPAP therapy and is at risk for untoward cardiac consequences of untreated OSA. Given that the patient has failed CPAP therapy and is an appropriate candidate for hypoglossal nerve stimulator implantation, Inspire hypoglossal nerve stimulation therapy is likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy at this time.Final Result: Two of the three reviewers determined that the requested therapy 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: All three reviewers are board certified in otolaryngology, and all three 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing.  Findings:  Two of the three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. Although the provider indicated that the patient has failed multiple medications, the records provided show that she was tried on Celexa and Zoloft, both in the selective serotonin reuptake inhibitor (SSRI) category. It does not appear that she was tried on serotonin-norepinephrine reuptake inhibitors or atypical antidepressants, such as Wellbutrin.  It also does not appear that electroconvulsive therapy was discussed. Studies have shown that clinically useful predictors in genetic testing are scarce for antidepressant therapy, with results being inconsistent. There is only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability in the treatment of depression. The existing studies have indicated that there is no significant correlation between either genotypes or medication serum concentration and response to treatment. The current evidence does not support the use of genotyping when choosing an antidepressant, and even less is understood about its use in the treatment of anxiety disorders. Genetic testing lacks evidence-based research to show its efficacy in guiding the clinician towards choosing a medication regimen. Therefore, genetic testing was not likely to have been of greater benefit than other method of evaluating this patient. 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 psychiatry 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 Humira pen (adalimumab pen-injector kit 40 mg/0.8 mL). Researchers note that Humira is FDA approved for the treatment of hidradenitis suppurativa. Humira is the only FDA approved medication for this condition. Researchers concluded in their three-year study that continuous weekly dosing with Humira is a reasonable treatment option for long-term control of moderate-to-severe hidradenitis suppurativa.In this case, the patient has tried and failed treatment with rifampin, mupirocin ointment, clindamycin and Hibiclens. Despite these attempts at conservative treatment, the patients condition continues to worsen. There are no other reasonable, alternative treatment options available. Therefore, Humira pens are medically necessary for treatment of this 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 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: An enrollee has requested reimbursement for genetic testing. This patient meets National Comprehensive Cancer Network guidelines for testing based on having close relatives diagnosed with breast cancer at age 50. The enrollee also has a family history of a grandmother diagnosed with lung cancer at age 40 and a father diagnosed with lymphoma at age 21. The largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5 to 10 percent have a BRCA1 or BRCA2 mutation, and about 4 to 7 percent have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may also be associated with increased risks for these cancers. Panel testing is now considered a standard of care. In sum, genetic testing was likely to be of greater benefit than other methods of evaluating this patient. Findings:  Two of the three physician reviewers found 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.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 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 fetal chromosomal aneuploidy testing (CPT 81420). Findings:  Three physician reviewers found the current medical evidence supports the services at issue in this patients case. The American College of Obstetricians and Gynecologists (ACOG) recognizes the option to choose noninvasive prenatal testing as a strategy to screen for aneuploidy regardless of the patient risk status. Given that the patient will be greater than 35 years of age at the expected time of delivery, she should be considered in a high-risk setting. ACOG endorses the discussion and use of noninvasive prenatal testing in this patient population. Therefore, fetal chromosomal aneuploidy testing (CPT 81420) was likely to have been of greater benefit than other methods of evaluating this patient. 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 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.