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

An enrollee has requested reimbursement for laboratory work [CPT 81422 - fetal chromosomal microdeletion(s) genomic sequence analysis (e.g., DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood]. Shaffer and Norton describe cell-free DNA (cfDNA) screening for the common aneuploidies as an accurate noninvasive screen for the common autosomal and sex chromosome aneuploidies. However, the authors note that due to the low prevalence of recurrent copy number variants, the clinical utility in screening for microdeletions and duplications is uncertain, is not recommended for the general obstetric population, and may not detect as many chromosomal abnormalities of importance when compared with traditional screening. Grati and Gross note that the use of cfDNA testing carries significant limitations and pitfalls, including the possibility of an absence of a result and the risk of possible discordance between cfDNA screening results and the actual fetal genetic chromosomal constitution. The American College of Obstetrics and Gynecology (ACOG) guidelines do not currently recommend testing for microdeletions in low-risk obstetric populations. In this clinical setting, current medical literature supports the use of conventional screening methods as the most appropriate choice for first-line screening for most women. Therefore, the laboratory work [CPT 81422 - fetal chromosomal microdeletion(s) genomic sequence analysis (e.g., DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood] was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for whole breast ultrasound. The records provided for review document that this patient underwent routine mammography studies and was found to have an area of architectural distortion in the setting of heterogeneously dense breast tissue. Due to these findings, the patient underwent evaluation with tomosynthesis examinations followed by whole breast ultrasound. Multiple modalities have been used to resolve the problem of the heterogeneously dense breast. Most recently, tomosynthesis has been demonstrated to yield additional data helpful in this diagnostic setting. When there are concerns following tomosynthesis, options include follow-up mammography, magnetic resonance imaging (MRI), and ultrasound. There are several peer-reviewed medical literature articles that support the use of whole breast ultrasound as an adjunct to mammography. Berg and colleagues found that whole breast ultrasound provided an increased detection rate of occult breast cancer when added to routine mammography. MRI of the breast has been shown to have a high level of sensitivity, but a relatively low level of specificity. For this patient, the whole breast ultrasound was performed concurrent with the additional left breast mammographic images, which is consistent with the recommendations in the medical literature. For these reasons, the whole breast ultrasound screening was medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 magnetic resonance imaging (MRI) of the left ankle. As noted in the medical literature, MRI provides an accurate method of observing and diagnosing injuries of the ligaments of the ankle, osteochondral fractures, articular cartilage injuries, and degenerative conditions. Clinical conditions that can present as posterior ankle pain include posterior ankle impingement, Achilles tendon and medial flexor tendon pathology, posterior subtalar tarsal coalition, sinus tarsi, and tarsal tunnel syndrome. This patient sustained an inversion injury to the left ankle, which has resulted in chronic ankle pain despite arthroscopy and debridement of the talus. X-rays have reportedly been negative. Thus, additional diagnostic studies are indicated for further evaluation of his chronic pain to help guide further treatment. Therefore, the requested MRI of the left ankle is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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 patient has requested authorization and coverage for liposuction (fat grafting of buttocks, using fatty tissue from the abdomen to fill in the buttocks). Findings:  The physician reviewer found that Pace and colleagues report, Soft tissue atrophy and skin hypopigmentation are rare but potentially distressing complications of corticosteroid injections (CIs). These changes usually manifest within several months of the steroid injection and will often resolve within one year. Guigni and colleagues state, Our results provide evidence for skeletal muscle atrophy and mitochondrial rarefaction in breast cancer patients that may be linked to the mitotoxic effects of chemotherapeutics. In this case, the patient reports long-standing indentations on her buttocks from childhood that have worsened post chemotherapy treatment, and her provider has noted a possibility that the appearance of her buttocks may be related to chemotherapy. While instances of fat tissue atrophy with corticosteroid injections and of skeletal muscle atrophy with chemotherapy have been reported, current medical literature does not support a relation of chemotherapy to localized fat atrophy, and the records did not document that the patient sustained a single site increase in localized fat atrophy as a result of generalized breast cancer chemotherapy. Therefore, in this clinical setting, liposuction (fat grafting of buttocks, using fatty tissue from the abdomen to fill in the buttocks) is not medically necessary for the 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. In this case, while it is not clear that the depression on the patients buttocks constitutes an abnormal structure of the body, it does not cause a functional loss. The appearance of the buttocks is normal, and the requested service would likely result in minimal improvement in appearance. Accordingly, the requested liposuction (fat grafting of buttocks, using fatty tissue from the abdomen to fill in the buttocks) is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition and is 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for cognitive processing therapy (CPT) and eye movement desensitization and reprocessing (EMDR) therapy.In both EMDR and CPT, the life-threatening trauma experienced by the patient is the focus of the therapy with various methods for the patient to re-experience and reframe those traumas. In this case, post-traumatic stress disorder (PTSD) has not been diagnosed by a psychiatrist, although the patient has been diagnosed with major depressive disorder (MDD). Additionally, the psychologist who has been seeing the patient mentions that the patient endorses various trauma-based symptoms but  has not had one big traumatic event. He has experienced a series of events in which hes felt traumatized. The details of the trauma perceived by the patient are not documented, and it seems that the predominant issue causing the patients difficulty in recovering from these experiences are the interpersonal slights he experienced but not specific traumas, and PTSD has not been diagnosed in this patient. Because of this, CPT and EMDR focusing on these traumatic experiences wouldnt be therapeutically indicated more than other psychotherapies based on evidence, and PTSD is the only evidence-based indication for these psychotherapeutic modalities. Therefore, CPT and EMDR are not medically 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 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 reimbursement for (1) bilateral breast implant removal surgery and (2) breast surgery (bilateral breast mastopexy). Tervaert and colleagues state, Autoimmune/inflammatory syndrome by adjuvants (ASIA), allergies, autoimmune diseases, immune deficiencies and lymphomas occur in patients with silicone breast implants. There is a need for adequately adjusted epidemiological studies to ascertain the frequency of these diseases. However, Balk and colleagues state, The evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. Chao and colleagues report, Breast implant surgery is one of the most commonly performed procedures in the field of plastic surgery. While silicone implants are now routinely used in breast surgery, they have previously been the subject of controversy. This was particularly true in the U.S., where there was a moratorium on their use from 1992 to 2006. Following subsequent scientific validation of their safety, silicone implants have regained widespread acceptance for clinical use. Overall, silicone breast implants are associated with a high degree of patient satisfaction and low rates of complications. Further independent research is necessary to better establish long-term outcomes. In this case, the patient reported generalized complaints associated with silicone breast implants. The documentation also noted that the implants that were removed were saline filled implants, not silicone gel implants. Given that current medical literature does not support the association of the patients symptomatology with her breast implants, the bilateral breast implant removal surgery was not medically indicated. While the provider noted that patient may not like the aesthetic of her breasts post removal and may request a mastopexy, breast surgery (bilateral breast mastopexy) was not medically indicated. Therefore, (1) bilateral breast implant removal surgery and (2) breast surgery (bilateral breast mastopexy) was not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for dynamic pelvic floor magnetic resonance imaging (MRI) defecography (CPT 72195).Findings: Two out of three physician reviewers found that the authorization and coverage for dynamic pelvic floor MRI defecography (CPT 72195) is not likely to be more beneficial for the enrollee than any available standard therapy.Anal manometry quantifies the rectal and anal pressure changes during attempted defecation and reflex changes during balloon distention and thereby identifies dyssynergic defecation (DD). Anorectal manometry with rectal sensory testing is the preferred method for diagnosis of DD and abnormal rectal sensation. Newer tests, such as high-definition anal manometry, may provide better understanding through three-dimensional and topographic mapping. Evolving tools such as motor evoked potentials may provide comprehensive neurophysiological information. Defecography is useful in patients with suspected rectal prolapse or poor rectal evacuation. The balloon expulsion test can confirm impaired evacuation, but by itself is not diagnostic. All of these tests are in the armamentarium of gastroenterologists and colorectal surgeons to evaluate defecatory disorders. MRI defecography is not superior to the aforementioned battery of tests listed. Studies do not demonstrate that MRI defecography is superior to the aforementioned battery of tests listed. Thus, dynamic pelvic floor MRI defecography (CPT 72195) is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection in the right knee (HCPCS Code J7325). Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients remaining treatment options are limited. The patient has tried and failed conservative treatments including aspiration and injection with steroids, and physical therapy, with the alternative being a total knee arthroplasty. Given these findings, the requested Synvisc One injection in the right knee (HCPCS Code J7325) 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. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Orencia 125mg/ml Clickject, 4ml/28 days. Findings:  The physician reviewer found that American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, addition of biologic disease-modifying antirheumatic drugs (DMARDs) (Tumor necrosis factor (TNF) inhibitors such as Enbrel or Humira, Orencia, IL-6 receptor inhibitors and rituximab) or target synthetic DMARDs ( Janus kinase (JAK) inhibitors such as Xeljanz or Rinvoq) is recommended in persons with rheumatoid arthritis who have not adequately responded to initial conventional DMARD therapy to maximize improvement as quickly as possible. Furthermore, the guideline indicates that based on available data, there is no current recommendation for biologic DMARD versus a targeted synthetic DMARD when adjusting therapy to optimize disease control. The guideline does not specify that one drug class is preferred over the other at this time based on current available data. In this case, the patient has uncontrolled inflammatory arthritis secondary to rheumatoid arthritis and systemic lupus and has failed conventional DMARD therapy. According to the guidelines, the patient is a candidate for therapy with a biologic DMARD, such as Orencia, as the next line of treatment. Therefore, the Orencia therapy is appropriate. The guideline does not indicate that Enbrel, Humira, Xeljanz or Rinvoq must be utilized first prior to Orencia. The guideline indicates that one agent is not considered as preferential therapy over the other. Furthermore, Enbrel and Humira are associated with the development of drug-induced lupus and are therefore avoided in persons having systemic lupus erythematosus, as in the case of this patient. Thus, Orencia 125mg/ml Clickject, 4ml/28 days is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested mediation 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 rheumatology 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 Xeljanz tablets. Findings: A study notes that open-label studies of ruxolitinib and tofacitinib (brand name Xeljanz) showed dramatic clinical responses in patients with moderate-to-severe alopecia areata. Another study reported that treatment with Janus kinase (JAK) inhibitors for 24 weeks in patients with alopecia areata was efficacious and generally well tolerated. Treatment of alopecia totalis includes systemic steroids, methotrexate, cyclosporine, JAK kinase inhibition, and contact sensitization with DPCP or Squaric acid. In this case, the patient has a diagnosis of severe alopecia totalis and has failed treatment with corticosteroid injections. Given that current medical literature supports the use of Janus kinase (JAK) inhibitors following failed treatments of first and second line therapies, in this clinical setting, the requested medication is medically indicated. Therefore, Xeljanz tablets are medically necessary for the 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.Credentials/Qualifications: The 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 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 a cystoscopy macroplastique injection. Findings:  The physician reviewer found that Gerhard and colleagues note that postprostatectomy incontinence (PPI) may lead to severe limitations and loss of quality of life. The authors further note that treatment may include fixed slings in cases of mild or moderate incontinence, adjustable devices for irradiated patients, and artificial urinary sphincters for severe incontinence. A trial of bladder neck bulking with a permanent agent may be useful prior to urinary diversion or catheterized channel and bladder neck closure, as while collagen injections may be repeatedly used after reabsorption in native bladder necks, post-operative injection sites will commonly accept only one injection. Given that PPI is not a temporary condition that is likely to resolve on its own, the requested service is medically indicated. Therefore, a cystoscopy macroplastique injection 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 urology 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.