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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing assay. In this case, the patients initial biopsy revealed a transection of the tumor as tumor infiltrating cells traveled down adnexa in the specimen and were possibly deeper than the initial biopsy. According to the National Comprehensive Cancer Network (NCCN) guidelines, this unusual clinical circumstance means that we cannot accurately fit this patients tumor into stage I or II. The value of accurate staging is to provide prognostic information in order to guide follow-up and treatment. In this patients case, the use of DecisionDx-Melanoma molecular genetic testing is likely to assist in guiding follow-up and further surveillance. If this patients tumor were to show results suggestive of a higher risk of metastasis, this would support closer surveillance and possible imaging. Since this is a unique clinical scenario without specific evidence-based guidelines, the DecisionDx testing for this patient was likely to be helpful to guide his follow-up care with his provider, and no other standard of care testing would have been able to provide these data. Given these findings, the DecisionDx-Melanoma genetic testing assay 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 DecisionDx-Melanoma genetic testing assay 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 reviewers 1, 2, and 3 are board certified in dermatology 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 enrollees parent has requested reimbursement for high frequency chest wall oscillation (HFCWO). Tracheomalacia is an anomaly of the upper respiratory tract characterized by dynamic collapse of the trachea during expiration, resulting in airway obstruction and poor mucous clearance. Left untreated, tracheomalacia leads to mucous impaction, recurrent pulmonary infections, and irreversible airway damage called bronchiectasis. In patients with bronchiectasis, HFCWO devices have been demonstrated to improve mucous clearance, thereby optimizing pulmonary hygiene to avoid irreversible airway damage from bronchiectasis. This patient required an aggressive mucous clearance program to forestall irreversible airway damage and avoid hospitalizations from recurrent pulmonary infections. Initiating therapy with a HFCWO device in this patient is within standard practice. Given these findings, the HFCWO device was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the HFCWO device was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the device at issue was 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: Physician reviewer 1 is board certified in pediatrics with subspecialty certification in pediatric pulmonology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in pulmonary disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in pulmonary disease 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: At issue is whether Norco is medically necessary to treat the patients medical condition. This is a patient that experiences chronic pain and arthritis in the back, hips and knees, fibromyalgia, gout, and severe kidney disease. The patient has been evaluated by orthopedics, physical medicine, and pain management. The patient takes Norco pain medication three times a day for pain relief. The last Norco refill is dated 12/13/19 for 90 tablets. The patient requested a Norco refill on 1/7/20. The provider requested a urine drug test. The urine drug test was positive for tetrahydrocannabinol (THC, the active ingredient in marijuana), opiates (contained in the Norco) and hydrocodone (contained in the Norco). The provider requested the patient to come in for an in-person discussion of the urine test results, a referral to pain management and an opioid medication agreement. The patient has declined to come in for the in-person visit and discussion with the provider. The researchers recommend that until scientific evidence is forthcoming, that opioid prescribers do not support patients concomitant use of marijuana, be it medically certified or illicit, and they should make continued opioid receipt contingent on marijuana use cessation. The submitted documentation shows the patient had THC in the urine drug test of 2/20 and that the patient signed an opioid agreement in 2018. The treating provider in this case has requested the patient come in to the office for an in-person discussion of the patients urine test results, the opioid medication agreement, and a referral, before any further opioid medication can be prescribed. This is a reasonable, prudent, and appropriate approach to the patients medical care and safety with the use of an opioid and THC. The submitted documentation shows that this patient has chosen to decline attending the requested in-person discussion with the provider. Therefore, Norco is not medically necessary to treat this patients condition.   Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology and pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for saturation biopsy (CPT 55706). Saturation biopsy of the prostate involves a transperineal or transrectal ultrasound guided biopsy. A standard biopsy includes sampling of 10-20 cores, while more than 20 cores are obtained using a saturation biopsy. Based on the current medical literature and guidelines, saturation biopsy is not considered standard of care for evaluation of patients with an elevated prostate specific antigen (PSA). The standard of care for this patient would have been magnetic resonance imaging (MRI) and considering a MRI fusion biopsy. Accordingly, the saturation biopsy (CPT 55706) 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 saturation biopsy (CPT 55706) 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 urology 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 breast reduction surgery.In this case, the patient complains of back and neck pain and has a history of a prior breast reduction. There is no report of chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Furthermore, while there is mention of shoulder grooving, it is not documented on physical exam or supported by photographs of the patient. Because there are less than two quality of life signs, the requested service would not be considered medically necessary according to ASPS criteria. In addition, the patients minimal resection of 400 grams per breast would be below the 22nd percentile of 764 grams per breast at a body surface area (BSA) of 2.11 and below the 5th percentile of 488 grams per breast at a BSA of 2.11. This would qualify the procedure as purely cosmetic according to weight. Combining this lack of determination of medical necessity based on weight with the lack of determination of medical necessity based on ASPS criteria, the requested breast reduction 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; or (2) to create a normal appearance, to the extent possible. In this case, the patient has back and neck pain, but there is no documentation that this pain is due to breast hypertrophy. Records indicate that the patient suffers from obesity, and weight loss was recommended. The patient has already undergone a breast reduction procedure and no further breast reduction is recommended for improvement in function. There is also no report in the submitted documentation that the patient does not have a normal appearance or that a breast reduction would cause more than a minimal improvement in her appearance. Accordingly, the requested breast reduction surgery is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients condition and are 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: Upheld Decision of Health Plan

An enrollee has requested reimbursement and authorization and coverage for osteopathic manual manipulation of the jaw and neck. Medical literature does not support that the services at issue and requested services are medically necessary. Clinical practice guidelines for tinnitus published by the American Academy of OtolaryngologyHead and Neck Surgery Foundation (AAO-HNSF) do not identify osteopathic manual manipulation of the jaw and neck as a recommended treatment. In addition, there are no studies in the literature that have shown benefit from osteopathic manual manipulation of the jaw and neck for tinnitus in well-controlled studies. In this case, the patient has persistent, bothersome tinnitus and insomnia. The patient has reported that tinnitus has resulted in a significant negative effect on his quality of life. Evidence-based clinical guidelines for the treatment of chronic tinnitus do not include osteopathic manual manipulation of the jaw and neck as a recommended treatment. Accordingly, the osteopathic manual manipulation of the jaw and neck services at issue, and two additional future visits, were not, and are not, medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medications, Carisoprodol 350mg tablet, and Zolpidem 10mg tablet dosed at two (2) tablets at bedtime. The enrollee has a history of chronic hip pain and chronic insomnia. The enrollee has additional diagnoses of major depressive disorder, single episode, and anxiety disorder. Records show the enrollee currently takes Cymbalta, 30 milligrams, and Remeron, 15 milligrams. The enrollee also takes Xanax for anxiety; 2 milligram tablets twice a day as needed. The physician documented physical symptoms of dizziness/vertigo, muscle weakness, tremors in the enrollees hands and muscle spasms. The progress note indicates the enrollee has a risk of substance abuse relapse. The physician ordered Ambien, 20 milligrams, at bedtime, until the enrollees hip pain has significantly reduced. After an urgent care visit, the treating provider requested soma for the enrollee, noting the enrollee had tried and failed baclofen and Flexeril. No specifics or documentation of the failure was reported in the records. Zolpidem is intended to be used for the short-term management of insomnia. The standard adult dosage is adults, five or 10 milligrams (men) or 5 milligrams (women) immediate-release or 6.25 or 12.5 milligrams (men) or 6.25 milligrams (women) extended-release immediately before bedtime. Maximum daily dose is 10 milligrams immediate-release and 12.5 milligrams extended-release. The dosage of 20 mg per day exceeds the maximum daily recommended dose. Also, the concurrent use of zolpidem and sedatives or hypnotics may result in an increase in central nervous system depressant effects.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in (insert specialty) and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: This is a patient that is experiencing symptoms of psoriasis and psoriatic arthritis. The patient experiences skin flares on 40% of the body and joint pain in the knees, elbows and shoulders. The provider states the patient has tried and failed clobestasol, Lidex, triamcinolone, Protopic, fluocinolone, Benadryl, certirizine, Eucerin, and Cetaphil without significant improvement and continues to have skin involvement, pain and itching despite current treatment with topical medications. The patient is also receiving photo therapy. The provider is requesting the Humira pen because the benefits outweigh the risks. The provider states that medications such as methotrexate, cyclosporine or acitretin are unsafe for this patient with hypertension, type 2 diabetes, hyperlipidemia, cataracts, and anemia as symptom control will require increasing doses which would put this patient at increased risk of toxicities and adverse effects. At issue is whether the Humira pen for psoriasis/psoriatic arthritis is medically necessary to treat the patients medical condition. The submitted documentation supports the medical necessity for use of the Humira pen for this patient. The options of methotrexate, cyclosporine, or acitretin are not medically appropriate for this patient. Methotrexate would be contraindicated due to the patients history of anemia which can be exacerbated with methotrexate. Cyclosporine would be contraindicated due to the patients history of hypertension. And, acitretin would be contraindicated due to the patients history of hyperlipidemia. Therefore, the Humira pen is medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 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 panniculectomy. According to the American Society of Plastic Surgeons (ASPS), a panniculectomy involves the removal of hanging excess skin/fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. This patients medical records do not include documentation that the patients panniculus hangs below the level of the pubis, or that the panniculus causes chronic intertrigo that recurs over three months despite appropriate medical therapy. Further, the photograph does not reveal that the panniculus hangs below the level of the pubis. The patient complains of a recurrent rash underneath her abdominal pannus during the summer months, but there is no documentation of appropriate medical treatment of the rash or of failure of appropriate medical treatment of the rash. Moreover, the records do not report a functional problem with the rash that has been resistant to appropriate medical treatment. Based on these findings, the requested panniculectomy is not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. An abdominal pannus is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. An abdominal pannus is not an abnormal structure of the body rather it is a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. The requested panniculectomy will not improve the patients function or provide a more than minimal improvement in the patients appearance. All told, the requested panniculectomy is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication progesterone, 200 mg tablets, 90-day supply. The enrollee has been diagnosed with menopause. Medical records show she has been on progesterone, 100mg, and had breakthrough bleeding. The enrollee also reports she had an endometrial biopsy that was negative for cancer. She discussed hormone replacement therapy with her gynecologist, and received information about the risks of increasing the dose of her progesterone medication. The physician ordered progesterone, 200mg, for her condition. Based on the information received, it appears that the enrollee is having bleeding because of too much progesterone, and increasing the dosage will cause even more bleeding. Her bleeding may likely be due to progesterone breakthrough bleeding; i.e., it occurs when the ratio of progesterone to estrogen ratio is high. Increasing progesterone may likely increase bleeding.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in obstetrics and gynecology and reproductive endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.