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 FoundationOne CDx genetic testing. The development of sophisticated genetic and molecular characterization of central nervous system neoplasms has shown that histologically similar neoplasms can be characterized more accurately for prognosis and in some instances for response to different therapies. Molecular characterization of primary brain tumors/gliomas has had a substantial impact on stratification and eligibility in clinical trials for central nervous system neoplasms over the last ten years and is increasingly becoming a common part of standard neuro-oncology management. The National Comprehensive Cancer Network guidelines recommend molecular profiling to identify clinically relevant subtypes to encourage opportunities for clinical trial involvement. Given the lack of efficacious treatments available for patients with glioblastoma, there is sufficient support for the use of molecular testing, such as FoundationOne CDx genetic testing. Therefore, FoundationOne CDx genetic testing was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy. Findings: Two of the three physician reviewers found FoundationOne CDx genetic testing was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to have been 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 internal medicine with sub-specialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept procedure (CPT 22899) with HCPCS C9752. While the clinical evidence does support the utility of the Intracept procedure in the setting of chronic low back pain, there are data suggesting that radiculopathy is an exclusion criteria for the use of this procedure. This patients records document a diagnosis of radiculopathy reported by his treating provider. The finding of radiculopathy was substantiated by the documented 80% relief with a selective nerve root block, which anesthetized a nerve outside of the spinal canal indicating that the patients pain is largely from radiculopathy. Therefore, the requested Intracept procedure (CPT 22899) with HCPCS C9752 is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested Intracept procedure (CPT 22899) with HCPCS C9752 is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment 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 orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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 surgical procedures including. The records provided for review document that the inferior alveolar nerve and its terminal branch, the mental nerve, are damaged. However, some nerve conduction is still present resulting in dysesthesias about one year after the trauma. This finding supports a differential diagnosis of axonotmesis or neuroma, both of which are treated by nerve graft, and supports the need for nerve suture and nerve graft. The patients lip ptosis is secondary to scarring from both the surgery and the subsequent infection, which were a result of the initial trauma. Thus, lip repair is also supported as medically necessary. The success rate for inferior alveolar nerve repair is 87%, resulting in an improvement in sensation and subsequently function (Motamedi). For these reasons, the requested surgical procedures including lip repair; nerve suture; and nerve graft are medically necessary. 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. Applying this statute, the requested surgical interventions are reconstructive in nature. The patients condition constitutes an abnormal structure of the body, and it was caused by trauma which is the initial reason for her hospital admission and subsequent surgery. The recommended surgical procedures will address the patients functional issues related to her condition and create a more than minimal improvement in the patients appearance. All told the requested surgical procedures are reconstructive in nature for the treatment of this patient. Given this support, the requested surgical procedures are medically necessary and reconstructive in nature for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in oral-facial and maxillary 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 patient has requested authorization and coverage for iron dextran, 50 mg x 20 units (for a total of 1000 mg). It is generally accepted practice to target normal iron saturation and ferritin levels before stopping repletion. In this case, the records demonstrate that the patient does not have anemia but does appear to have low iron stores despite taking oral iron, indicating that further repletion is necessary. In this clinical setting, the patient may be maintained on oral iron with follow-up of her iron indices and blood hemoglobin and complete blood counts. A lack of improvement after two months in iron stores or indices, such as the saturation and ferritin, may indicate that the patient is not absorbing oral iron. Given that the patient appears to have recovered from anemia and additional time on oral iron may replete her iron stores, the requested medication is not medically indicated at this time. Therefore, iron dextran, 50 mg x 20 units (for a total of 1000 mg) 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 internal medicine with sub-specialty certification in hematology 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 The patient has requested authorization and coverage for the Libre 14-day reader and sensor. Olczuk and Priefer report that self-monitoring of glucose allows patients with diabetes mellitus to take control of their disease and thus directly affect the outcomes related to it. Zheng and colleagues note that continuous glucose monitoring (CGM) systems may be clinically valuable due to their accuracy and convenience and may promote glycemic and weight control, helping to reduce the risk of hypoglycemia and hyperglycemia. The authors further note that CGMs are a useful tool for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. Given that current medical literature supports the safety, efficacy, and accuracy of CGMs, the requested equipment is medically indicated. Therefore, the Libre 14-day reader and sensor are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for radiofrequency ablation of the right greater saphenous vein, varicose vein microphlebectomy. Obi and colleagues noted that in a study of 1,406 patients with varicose veins, endovenous treatment of axial reflux was the preferred treatment in 89.1%, divided largely between radiofrequency ablation at 55.2%, and endovenous laser ablation at 33.9%. In this case, the submitted records note the presence of pedal pulses and severe reflux in the vein to be treated, along with suitable diameters. Given that the records note that the patients symptoms are of a severity to limit daily activities despite efforts at conservative treatment, the requested service is medically indicated. Therefore, radiofrequency ablation of the right greater saphenous vein, varicose vein microphlebectomy, is medically necessary for the treatment 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 vascular 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for robotic assisted total knee arthroplasty of the left knee. The records provided for review document that this patient presents with left knee osteoarthrosis. The patient is planned to undergo total knee replacement with use of robotic assistance. The current standard of care for total knee arthroplasty includes use of traditional instrumentation and techniques. Excellent long-term functional and patient reported outcomes have resulted with these methods as substantiated in many high-level published reports. Short- and medium-term follow-up studies of robotic assisted total knee arthroplasty have shown slight improvements over traditional methods in terms of component alignment, but this has not translated to improved functional and patient reported outcomes. Given the current absence of robotic long-term outcomes, superiority over traditional total knee arthroplasty has not yet been established. Accordingly, the requested robotic assisted total knee arthroplasty of the left knee is not 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 requested robotic assisted total knee arthroplasty of the left knee  is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment 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 orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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: The patient has requested authorization and coverage for a Volara system oscillation and lung expansion device (E1399). Chest physiotherapy devices, such as oral oscillating devices, high frequency chest wall oscillating devices, external percussion vests, and intrapulmonary percussive ventilation such as the Volara system, have been the cornerstone of mucous clearance in the management of cystic fibrosis and other forms of bronchiectasis. However, data supporting the use of chest physiotherapy devices in the management of COPD is limited. Given the lack of support in current medical evidence supporting the efficacy of a Volara system in this clinical setting, the requested device is not medically indicated. Therefore, a Volara system oscillation and lung expansion device (E1399) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 certifications in pulmonary disease and in critical care 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: 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 (IORT) of the right breast. IORT with accelerated partial breast irradiation (APBI) is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria. APBI may be delivered using external beam radiotherapy, brachytherapy, or IORT. For APBI delivered using IORT, there is a phase III randomized data of over 3400 patients supporting its use that reported equivalent four-year local control rates between IORT and external beam whole breast radiotherapy. Available data includes 8.6-year follow-up results that continue to show non-inferiority with regards to local recurrence-free survival, mastectomy-free survival, and distant disease-free survival. All told, the requested IORT of the right breast is likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested IORT of the right breast is likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for the 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 radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for tobramycin 300 mg/5 mL inhalation solution/powder. Based on the available information, the requested tobramycin 300 mg/5 mL inhalation solution/powder is medically necessary for the management of this patients condition. Loebinger and colleagues reported that tobramycin significantly reduced the P. aeruginosa sputum density from baseline to day 29 versus placebo in a dose-dependent manner. Moreover, the European Respiratory Society (ERS) guidelines support a therapeutic trial of inhaled antibiotics for patients with P. aeruginosa in their sputum who are experiencing significant morbidity from acute exacerbations (Polverino, et al.). The records provided for review document that this patient has pseudomonas in sputum, and has demonstrated significant morbidity based on recurrent chest infections requiring IV antibiotics despite maximal medical management with an aggressive mucous clearance program. Given this support, the requested tobramycin 300 mg/5 mL inhalation solution/powder 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage rifaximin (Xifaxan). The records provided for review document that this patient has IBS-D and SIBO. The patients provider has recommended treatment with Xifaxan. As noted in the medical literature, Xifaxan has been demonstrated to be safe and effective for the treatment of IBS-D (Lembo, et al.). In addition, the U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D. In the TARGET-3 trial of over 1,000 patients Xifaxan was reported to be effective with significant symptom improvement in patients with IBS-D (Lembo, et al.). Moreover, Xifaxan has proven highly effective in SIBO for eradication of bacteria and symptom relief (Scarpellini, et al.). Xifaxan showed greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and ciprofloxacin (Gatta and Scarpignato). For these reasons, the requested rifaximin (Xifaxan) is medically necessary for 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patients parent has requested reimbursement for bilateral mastectomy with chest reconstruction surgery services. Coleman and colleagues noted that chest surgery in female-to-male patients can be performed before age 18 preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. These findings are consistent with Olson-Kennedy and colleagues report that, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. There is no requirement or recommendation to wait until 18 to treat gender dysphoria in transmasculine youth with chest surgery. In this case, the medical necessity of the bilateral mastectomy and chest reconstruction has been established by the patients providers. Moreover, the bilateral mastectomy services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the bilateral mastectomy with chest reconstruction surgery services were medically necessary for treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage acupuncture. Based on the current peer-reviewed medical literature, the requested acupuncture is medically necessary for treatment of this patients nausea related to her infertility treatment regimen. Morehead and Salmon reported that the efficacy of acupuncture has been proven for nausea and vomiting related to pregnancy, in patients receiving chemotherapy, and in postoperative, pediatric, and female patients. This patients nausea secondary to infertility medications may respond favorably to treatment with acupuncture as noted in the medical literature (Lee, et al.). The patient should undergo a trial of treatment with acupuncture, and additional treatment sessions should be supported with a positive response. Given this support, the requested acupuncture is 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.