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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for genetic cancer susceptibility panels (Guardant360 testing). The enrollee has a diagnosis of stage IV non-small cell lung carcinoma. He reported developing a dry cough that did not improve with inhalers and systemic treatment.  A chest x-ray showed a large left sided mass. A computed tomography (CT) scan showed a 6.8 x 5.8 cm left lower lobe (LLL) mass extending to the hilum with mild spiculated margins and surrounding ground glass opacifications.  A positron emission tomography (PET) scan confirmed a fluorodeoxyglucose (FDG)-avid 5.9 x 7.5 x 6.5 LLL mass with standardized uptake value (SUV) 19.5, FDG-positive left mediastinal and hilar nodes, a right fifth rib lesion and an L4 lesion.  A CT-guided biopsy of the lung mass confirmed primary adenocarcinoma of lung with lepidic growth pattern. Documentation notes the provider ordered Guardant360 for the enrollee to determine if his current treatment regimen was optimized to manage his care.  The provider wanted to determine if there were targeted therapy options before beginning treatments. The Guardant360 test results revealed three somatic alterations with one associated, approved therapy. Literature notes genotyping of tumor tissue to find alterations that can inform practice and guide treatment has become a routine practice in clinical oncology. However, this practice has significant inherent limitations; such as selection bias and the difficulty of obtaining a representative sample. Professional societies have not established standards or guidelines for the use of (cfDNA)/circulating tumor DNA testing for genetic alterations, due to the high false-positive rate of 30% and  the presence of other alterations not related to the tumor. Literature notes the Guardant360 is not currently approved by regulatory bodies. Professional organizations do not support the liquid version of the test; only the tissue version. The value of Next Generation Sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise but is not yet ready for routine clinical use. There is no peer-reviewed literature to show the test would improve the patient's outcome.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in medical oncology and 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for facial feminization surgeries (CPT 21137 reduction forehead contouring; CPT 67900 repair brow ptosis; CPT 21139 reduction forehead; contouring and setback of anterior frontal sinus wall; CPT 30410 rhinoplasty, primary; complete, external parts including body pyramid, lateral and alar cartilages, and/or elevation of nasal tip; CPT 21122 genioplasty; sliding osteotomies, two or more osteotomies;  CPT 21209 osteoplasty, facial bones; reduction). Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. Moreover, the World Professional Association for Transgender Health (WPATH) supports facial feminization surgery in well-selected patients. WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. In addition, these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Researchers demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. In this case, the therapist attests to the medical necessity of the requested facial feminization surgeries, given the patients distress related to the presence of her masculine facial features. Moreover, the surgeon described the patients specific masculine facial features that will be addressed with the requested surgical procedures. All told, the requested facial feminization surgeries (CPT 21137 reduction forehead contouring; CPT 67900 repair brow ptosis; CPT 21139 reduction forehead; contouring and setback of anterior frontal sinus wall; CPT 30410 rhinoplasty, primary; complete, external parts including body pyramid, lateral and alar cartilages, and/or elevation of nasal tip; CPT 21122 genioplasty; sliding osteotomies, two or more osteotomies;  CPT 21209 osteoplasty, facial bones; reduction) are 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. 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

The patient has requested authorization and coverage for H.P. Acthar 80 unit/mL. Acthar Gel was designed as a bridge therapy and not a maintenance therapy for inflammatory conditions. This patient requires maintenance therapy with a biological agent other than those failed in the past. The records document that the patient has been refractory to steroids including Rayos. Additional treatments have included methotrexate, Plaquenil, and sulfasalazine, as well as Enbrel and Humira. The patient has not exhausted the available treatment options for rheumatoid arthritis. Additional therapies include Orencia, Xeljanz, and Actemra, as well as biological therapies proven effective for patients with rheumatoid arthritis that has been refractory to disease modifying anti-rheumatic drugs (DMARDs). Acthar has not been demonstrated to be superior to steroids or other biological agents in terms of efficacy or safety. Due to corticotrophin properties, Acthar gel is associated with the same adverse effects expected with steroids. The physician reviewer found that ongoing clinical trials are underway to evaluate the safety and efficacy of Acthar in the treatment of rheumatoid arthritis. Therefore, the requested H.P. Acthar 80 unit/mL is not medically necessary for 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Zio Patch. Based on the records provided for review, this patient presented with complaints of intermittent heart pounding and palpitations. For evaluation for dysrhythmia, serial 48-hour Holter monitoring, offline self-activated, or auto-triggered cardiac event monitoring would be sufficient first steps in recording the patients cardiac rhythm during symptoms. There is no documentation to indicate that the patient is not able to effectively manage these types of devices or that these devices have already been tried and failed. Current expert consensus guidelines endorsed by several national organizations consider patient-activated or auto-triggered event recorders appropriate initial tests and the standard of care for evaluation of dysrhythmias. Continuous real-time monitoring with telemetry services, such as with the Zio Patch, have not been shown to be more helpful than patient-activated or auto-triggered event recorder devices in in this clinical setting. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services such as with the Zio Patch has not been shown to improve health outcomes compared to standard monitoring techniques. Therefore, the Zio Patch was not and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the Zio Patch was not and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be upheld. Final Result: The reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patient's 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 subspecialty certification in cardiovascular disease 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: The patient has requested authorization and coverage for trigeminal nerve injections and greater occipital nerve injections. The American Headache Society (AHS) expert consensus recommendations noted that there is a paucity of evidence from controlled studies supporting the use of peripheral nerve blocks in the treatment of primary and secondary headache disorders, with the exception of greater occipital nerve blockade for cluster headaches. The researcher and colleagues concluded that there are limited data on the efficacy of peripheral nerve blocks for headaches. Researcher and colleagues reported that, the block of the greater occipital nerve with an anesthetic and corticosteroid compound has proved to be effective in the treatment of cluster headache. Regarding the treatment of other headaches and cranial neuralgias, controlled studies are still necessary to clarify the real role of peripheral nerve block. In this case, the patient has a history of chronic headache and migraines. She has been treated with Botox injections every 10 weeks while also receiving peripheral nerve blocks of the greater occipital nerve and the peripheral branches of the trigeminal nerve in the form of supratrochlear, supraorbital, and auriculotemporal nerves in between her Botox treatments. The AHS states that there is a lack of evidence for peripheral nerve blocks for headache disorders other than cluster headaches, which is not this patients current diagnosis. Based on the available medical records for review and evidence in the peer-reviewed medical literature, the requested trigeminal nerve injections  and greater occipital nerve injections are not medically necessary for treatment of this patient.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 in anesthesiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin.Nutropin AQ Nuspin is one of several FDA-approved formulations of somatotropin (growth hormone). FDA-approved indications for somatotropin in youth with open physes include growth hormone deficiency (GHD) evidenced by multiple clinical criteria such as hypoglycemia or length small-for-gestational age (SGA) in the newborn period, pathological GH or IGF-I gene mutation, or growth failure during childhood or adolescence (e.g., height z-score more than 1.5 standard deviations below MPTH z-score after adjusting for bone age; height z-score below -2; growth velocity below 10th percentile; IGF-I z-score below -2; IGFBP-3 z-score below -2; failure of peak circulating GH level to exceed 10 ng/mL either upon insulin-induced hypoglycemia or after two independent provocative agents other than insulin administered to a non-obese child).  Other FDA-approved indications for somatotropin in youth with open physes include SHOX gene haplosufficiency, Noonan syndrome, Turner syndrome, idiopathic short stature with height z-score below -2.25, growth failure due to renal insufficiency prior to renal transplant, and SGA with failure to display catch up growth by age 2 years.In this case, the patient is obese and with normal stature, and he displays a growth velocity that is consistent with his early pubertal development (Tanner stage 2). The failure of GH to rise after modest provocation, despite some priming by puberty, is a well-recognized, spurious phenomenon in obese pediatric patients who have intact GH production. The submitted documentation does not support any FDA-approved indication for somatotropin with respect to the patient. Under these circumstances, Nutropin AQ Nuspin is not medically necessary for the patients medical condition.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an oral appliance device (E0486). According to the International Classification of Sleep Disorders, Third Edition, (ICSD-3), a diagnosis of OSA is supported by the presence of symptoms such as excessive daytime sleepiness, fatigue, snoring, and non-restorative sleep, as well as comorbidities such as hypertension, psychological disorders, and/or five or more events of obstructive events on polysomnogram or home sleep study. Based on the polysomnogram results, this patient requires treatment for his mild OSA. The patient reports that he could not use CPAP, and his provider recommended an oral appliance. As the patient could not tolerate or refused CPAP treatment, alternative treatment with oral appliance is indicated to treat his symptoms in addition to possible benefit of managing his underlying polycythemia vera. All told, the requested oral appliance device (E0486) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 expertise in sleep 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for double mastectomy with nipple reconstruction.The World Professional Association for Transgender Health (WPATH), a worldwide authority on transgender health issues, has stated that chest surgery in transgender male patients is often of greater practical significance in the patient's daily life than reconstruction of the genitals (WPATH 2016). The WPATH Standard of Care, version 7, clearly mentions that chest surgery in Female to Male (FTM) patients could be carried out earlier than the age of majority. Mastectomy with male chest reconstruction in transgender male youth is now commonly done in minors, and has been demonstrated to be a safe and effective treatment for gender dysphoria in this population. In this case, the patient has a long history of gender dysphoria, and he has been living as male, on testosterone. The patient has substantial documentation from the medical team at his gender clinic program as well as from psychologists of gender dysphoria regarding his chest, and documentation of clinically significant symptoms supporting the medical necessity of bilateral mastectomy with male chest reconstruction. Under these circumstances, the requested double mastectomy with nipple reconstruction is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Injectafer parenteral iron infusions (CPT code J1439). Some patients with reduced or absent iron stores who have not yet developed anemia may have symptoms such as fatigue or reduced exercise tolerance (Vaucher, et al.). Although this patients anemia has improved, her iron stores remain low. The recommended treatment regimen with IV Injectafer is likely to improve the patients symptoms, and failure to treat is likely eventually to result in recurrent health issues (Camaschella). Intravenous iron is medically necessary since the patient is unable to tolerate oral iron and needs to have her stores replenished. Therefore, Injectafer parenteral iron infusions (CPT code J1439) are 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. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee has diagnoses of autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and major depressive disorder (MDD). He was diagnosed with ASD at age three and enrolled in an Individualized Education Program (IEP) from age three until age ten, with full inclusion in a classroom with an aide. His parents removed him from public school due to behavioral issues; after which he was home schooled.  He was verbally and sometimes physically abusive toward others.  He was admitted for psychiatric hospitalization due to holding a knife to his chest.  He entered the RTC program last fall.  His initial psychiatric assessment noted his last suicidal and homicidal ideations were two months prior.  He continued his home medications. Dose titration of Abilify was initiated and tolerated. He appeared ready to transition to a lower level of care and was discharged. The Child and Adolescent Level of Care Utilization System (CALOCUS), level of care assessment tool, was utilized to support accurate level of care determination. The enrollees composite CALOCUS score is 19, which correlates with intensive outpatient services. Medical evidence does not support the services at issue in this clinical setting.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent 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 similar medical condition.