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 the gene test (Panorama screening testing). Findings: Two of the three physician reviewers found that there is sufficient support for the services at issue in this patients case. Noninvasive prenatal screening by cell-free DNA testing is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is more sensitive than sequential screening and does not require the invasive procedure of chorionic villus sampling or amniocentesis. Therefore, the gene test (Panorama screening testing) 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 reviewer one, is board certified in clinical biochemical genetics and is actively practicing. Physician reviewer two is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer three is board certified in clinical cytogenetics and genomics and is actively practicing. All 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 the medication Lyrica. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees thoracic radiculopathy. At issue in this case is whether the requested medication Lyrica is medically necessary for treatment of the enrollees medical condition. Researchers noted that Lyrica was effective moderately for neuropathic pain related to radiculopathy. Enke and colleagues noted systematic review of published work supported that Lyrica was beneficial for neuropathic pain related to radiculopathy.Lyrica is recommended for the treatment of neuropathic pain.  The medical records provided for review indicate a pain condition consistent with neuropathic pain. As such the records do support use of Lyrica. Therefore, the medication Lyrica is medically necessary.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 overturnedCredentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in 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 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 transgender male enrollee has requested authorization and coverage for gender-affirming mastectomy. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) 7 reports that chest surgery in female-to-male patients can be performed after ample time of living in the desired gender role and after one year of testosterone treatment. WPATHs SOC 7 further noted that age does not preclude the medical necessity of chest surgery for transgender male adolescents. The WPATH SOC 7 states that chest surgery may be done in minors, and suggests, but does not require, a year of testosterone treatment. In the several years since the release of WPATH SOC 7, chest surgery in transgender male adolescents has become an effective and routine procedure. In addition, many transgender male adolescents find binding uncomfortable, and negative health effects have been reported. The providers in this case have documented the presence of persistent gender dysphoria related to the patient binding her chest. As the surgery will directly address the patients female appearing breasts, the distress related to this condition should be alleviated. All told, the requested gender-affirming mastectomy is medically necessary to treat this patients medical condition. Given these findings, the requested surgery is supported by the WPATH as medically necessary for treatment of this patients gender dysphoria. Final Result: The reviewer determined that the requested surgery 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The representative of an enrollee has requested reimbursement for Guardant360 genetic testing. Per the National Comprehensive Cancer Network (NCCN) guidelines, EGFR, ROS1, ALK, and BRAF testing was appropriate in this clinical setting. Per the NCCN guidelines, it has not been determined if molecular markers are useful in treatment determination and prognosis other than tests referenced above. The Guardant360 testing offers a comprehensive panel of molecular genetic markers on an individuals tumor to identify markers than can help guide therapy decision making. As Guardant360 provides genetic testing to guide therapy, and this is the subject of an ongoing phase II trial, there is a lack of data to support its routine use in the evaluation and treatment of patients with adenocarcinoma. Thus, the EGFR, ROS1, ALK, and BRAF portions of the testing were likely to be more beneficial for evaluation of the patients medical condition than any available therapy, while the remainder of the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available therapy.One reviewer found that the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available therapy.Final Result: Two of the three reviewers determined that a portion of 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 partially overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine and medical oncology and is actively practicing. One Reviewer is board certified in internal medicine, oncology, and hospice and palliative medicine and is actively practicing.  One Reviewer is board certified in internal medicine, hematology, and oncology and is 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential detoxification services. The submitted documentation supports the medical necessity of the residential detoxification services. The American Psychiatric Association treatment guidelines for Substance Use Disorders recommends that residential treatment, or similar care higher than outpatient, 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, and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. Such patients require safe and stable living environments in order to develop their recovery skills, thus qualifying for ASAM Level III treatment, which is at least residential or inpatient treatment similar to what the patient received at the facility. In this case, the patient had severe illness and continued his use of drugs despite the risks of DUI to self (including incarceration) and others. The patient also had a remitting relapsing illness despite many prior engagements in treatment. Under these circumstances, residential detoxification services were in accordance with generally accepted standards of medical practice and were clinically appropriate for the patient's illness. Accordingly, the residential detoxification services provided to the patient were medically necessary for treatment of the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients condition. Therefore, the patient should be reimbursed for the services at 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left knee replacement surgery. This patients evaluation revealed chondromalacia of patella but no degenerative changes in the medial or lateral compartments. The menisci are also intact. The requested surgical procedure of a total knee replacement surgery necessitates presence of severe degenerative arthritis in at least one compartment, and lesser grade arthritis in at least one additional compartment. In the absence of osteoarthritis on the imaging studies, the pain generator has not been established, and the expectations of complete pain relief will not be consistent with the outcome. Furthermore, the records document radiation of the pain to the hip and lower back which has not been thoroughly evaluated. In the absence of significant degenerative joint disease on the imaging studies, a total knee replacement surgery is not supported by the medical literature. In light of the foregoing, the requested left knee replacement surgery is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for Nutropin AQ Nuspin. The records provided for review do not establish the medical necessity of the requested GH therapy for treatment of this patients short stature. The documentation suggests that this patients height, pre-treatment growth velocity, and bone age are normal. Further, the patients predicted adult height is within two standard deviations of his target height and normal for U.S. adult males. In addition, his pre-treatment growth factors were appropriate for his bone age and he has no known morphological abnormalities of the pituitary gland or midline structures. All told, the requested Nutropin AQ Nuspin is not supported as medically necessary for treatment of this patients short stature.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hormone implants (subcutaneous testosterone implants), codes S0189, 11980 and J3490. Findings:  Three physician reviewers found that the diagnosis of testosterone deficiency is not well-defined in women, as there is a lack of biochemical criteria for this diagnosis. Current guidelines recommend against the generalized use of testosterone. Testosterone replacement therapies in postmenopausal women are not approved by the U.S. Food and Drug Administration (FDA) because of limited clinical trial data, limited efficacy compared with placebo and concerns regarding long-term safety. In sum, the superior effectiveness of hormone implants (subcutaneous testosterone implants), codes S0189, 11980 and J3490 has not been established. Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the services for temporomandibular joint dysfunction. Findings:  Three physician reviewers found the current well accepted method to identify the presence or absence of TMJ dysfunction is a comprehensive evaluation of the patients history and clinical examination. There are additional diagnostic tests and studies that are employed in the treatment of TMJ dysfunction. However, the evidence for the use of these modalities in the differential diagnosis or monitoring of TMJ dysfunction and orofacial pain is not supported in the literature. Although, transcutaneous electrical nerve stimulation (TENS) has been used for pain control, its role in the treatment of TMJ dysfunction as compared to traditional therapies has not been demonstrated in the peer-reviewed medical literature. Accordingly, the TMJ dysfunction services were 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 TMJ dysfunction services were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 is board certified in otolaryngology with subspecialty certification in plastic and reconstrutive surgery and is actively practicing. Physician reviewers 2 and 3 are board certified in maxillofacial surgery 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

A male enrollee has requested authorization and coverage for the medication methadone. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic pain, degenerative neck and back disease. At issue in this case is whether the requested methadone is medically necessary for treatment of the enrollees medical condition.The CDC guidelines do not recommend opiates for chronic pain in patients with a history of drug abuse. The Federation of State Medical Boards similarly, does not support the use of chronic opiates in a patient with a substance abuse history. Therefore, the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam therapy. The National Comprehensive Cancer Network (NCCN) guidelines noted that there is a lack of evidence to support proton therapy over IMRT for either treatment efficacy or long-term toxicity. Further, the American Urological Association (AUA) guidelines state that providers should inform localized prostate cancer patients who are considering proton beam therapy that it offers no clinical advantage over other forms of definitive treatment. All told, the proton beam therapy provided not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the proton beam therapy provided 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 proton beam therapy provided not 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement of Mopath Procedure Level 2 laboratory services. SMA is an autosomal recessive disease characterized by degeneration of spinal cord motor neurons that leads to atrophy of skeletal muscle and overall weakness. The disorder is caused by a mutation in the gene known as the survival motor neuron gene (SMN1), which is responsible for the production of a protein essential to motor neuron function. Because of the severity and relatively high carrier frequency, there has been increasing interest in carrier screening for SMA in the general prenatal population. The American College of Obstetricians and Gynecologists (ACOG) recommends screening for SMA in all women who are considering pregnancy or are currently pregnant. Further, the ACOG also states that ethnic-specific, panethnic, and expanded carrier screening are acceptable strategies for prepregnancy and prenatal carrier screening. Given these findings, screening for SMA in her subsequent pregnancy was medically indicated. Accordingly, the Mopath Procedure Level 2 laboratory service was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the Mopath Procedure Level 2 laboratory services was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service at issue was 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology and is 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for skilled nursing care, and authorization and coverage for ongoing skilled nursing care. Findings:  The physician reviewer found that the submitted documentation does not support that the services at issue were, or that the requested ongoing services are, medically necessary for treatment of the patients medical condition. Any patient admitted to a skilled nursing facility must show evidence of benefit from skilled therapy or the need for skilled nursing, such as wound care or IV antibiotics. Specifically, if an admission is for the purpose of rehabilitation, one must anticipate that progress in therapy would be made and that there would be concrete goals with which therapists could work. In this case, the patients limitation of weight bearing in her bilateral lower limbs (heel weight bearing only) and right upper limb weight bearing presents a significant functional logistical challenge for the therapists. Her function remains at the maximal assist level for bed mobility, transfers, dressing, and toileting, and for the near future will remain so. Due to diffuse fractures and weight bearing restrictions, her potential for functional improvement at this time is very limited. She has shown no potential to improve in therapy, and thus an alternate level of care would be appropriate. At a later time when her clinical picture improves, she will likely benefit from skilled nursing facility or acute level rehabilitation. Accordingly, skilled nursing care to the present date was not medically necessary for the patient, and ongoing skilled nursing care is not medically necessary for the patient at this time.Final Result: The reviewer determined that the services at issue and 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 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.