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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the laboratory testing for antibodies for adalimumab (CPT code 84999). In this case, Anser ADA was performed to direct the management of the patients collagenous colitis. Based on current peer-reviewed medical literature, the use of Anser ADA has not been proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action is not supported in the scientific data. The American Gastroenterological Association (AGA) guidelines for the treatment of collagenous colitis have not included the Anser ADA test in their recommendations.  The published studies on the use of anti-adalimumab antibodies and serum levels in other diseases such as inflammatory bowel disease are retrospective and/or observational in nature. One study found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibodies and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. For these reasons, the laboratory testing for antibodies for adalimumab (CPT code 84999) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the laboratory testing for antibodies for adalimumab (CPT code 84999) was 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 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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: The patient has a history of irritable bowel syndrome constipation-predominant for seven to eight years. The patient has requested authorization and coverage for the medication Xifaxan. The Health Plan has denied the request as not medically necessary as the patient has not tried and failed (or is contraindicated to) both ciprofloxacin and amoxicillin/clavulanate.At issue in this case is whether the requested medication Xifaxan is medically necessary to treat the patients medical condition.Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. The medication had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. Amoxicillin/clavulanate, the other formulary alternative, is associated with a high risk of adverse gastrointestinal symptoms including antibiotic-associated diarrhea. Results are sustained for several weeks after treatment with Xifaxan. One more recent study has corroborated this finding. A prospective trial of patients with irritable bowel syndrome and a positive breath test found that 86 percent responded to Xifaxan, and symptoms were reduced as well. The dose and duration of 550 mg twice daily for 14 days is consistent with regimens used in studies, which vary widely. The patient has small intestinal bacterial overgrowth confirmed by breath test. The patient has failed treatment with Cipro, Linzess and Trulance. Xifaxan has been proven effective in the treatment of small intestinal bacterial overgrowth. For these reasons, the use of Xifaxan is medically necessary for the treatment of this patients small intestinal bacterial overgrowth.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 internal medicine with subspecialty certification in gastroenterology 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

An enrollee has requested reimbursement for Doppler-guided transanal hemorrhoidal dearterialization. Findings:  Two of the three physician reviewers found that per American College of Gastroenterology guidelines, Doppler-assisted hemorrhoidal artery ligation has success rates comparable to hemorrhoidectomy and stapled hemorrhoidopexy. Studies have shown that it is comparable to conventional surgical hemorrhoidectomy for advanced hemorrhoidal disease in efficacy and safety. Given lower post procedure pain compared with alternatives, Doppler-assisted hemorrhoidal artery ligation has been reported as first-line treatment in the setting of grade 3 hemorrhoids. The procedure can include repair of mucosal prolapse. The technique at issue preserves the anatomy and physiology of the anal canal when compared to other surgical treatments for hemorrhoids, averting impaired anal function and fecal incontinence. For these reasons, Doppler-guided transanal hemorrhoidal dearterialization was likely to have been of greater benefit than other available treatment options. Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 authorization and coverage for factor II (prothrombin) DNA analysis laboratory testing. Findings:  Three physician reviewers found venous thromboembolism is common problem, with multifactorial causation. The G20210A mutation is a gain-of-function mutation that increases the prothrombin level to 30% above normal levels. With regards to patients who are positive for prothrombin G20210A and have a positive family history of clotting, the risk of venous thromboembolism increases three-fold to four-fold over the general population risk. This risk is higher when the venous thromboembolism occurred at a younger age or when there are multiple affected family members. In this patients case, the records document a family history of a clotting disorder in both his sister and maternal grandmother. His personal history is significant for right upper extremity deep vein thrombosis at a young age. The results of this testing are likely to impact the management of this patient. The treating provider noted that the results of the testing may impact whether the patient continues anticoagulation. Thus, factor II (prothrombin) DNA analysis laboratory testing is likely to be of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewers 2 and 3 are board certified in clinical genetics and genomics 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: A patient has requested reimbursement for the endovenous ablation therapy, with transcatheter delivery of a chemical adhesive to the right small saphenous vein. Findings:  Two physician reviewers found that the decision to use VenaSeal versus an alternate technique for vein ablation is supported in the current peer-reviewed medical literature. As concluded by one study, VenaSeal cyanoacrylate closure is safe is safe and effective for the treatment of one or more incompetent saphenous or accessory saphenous vein. Similarly, another medical study found that use of cyanoacrylate closure is safe and effective. This patients Doppler study revealed no evidence of deep vein thrombosis, small saphenous reflux via the sapheno-popliteal junction and left small saphenous vein reflux. Considering the scientific data in support of the procedure performed in this clinical setting, the endovenous ablation therapy, with transcatheter delivery of a chemical adhesive to the right small saphenous vein was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the endovenous ablation therapy, with transcatheter delivery of a chemical adhesive to the right small saphenous vein was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in surgery with subspecialty certification in general vascular surgery and is actively practicing. One Reviewer is board certified in surgery with subspecialty certification in general vascular surgery and is actively practicing.  One Reviewer is board certified in surgery with subspecialty certification in general vascular surgery 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the lab tests (CPT code 83520 and 8352059). Monoclonal gammopathy is a potential reversible cause for neuropathy. The appropriate testing by serum protein electrophoresis is considered within the standard of care when evaluating a patient for neuropathy without apparent etiology. A medical literature reviewed the standard battery of tests for neuropathy to help identify reversible causes for neuropathy. The authors concluded that serum protein electrophoresis is recommended for evaluation of neuropathy in this clinical setting. As this patient presented with neuropathy of unknown etiology, the lab tests (CPT code 83520 and 8352059) were likely to be more beneficial for evaluation of the patients condition than any available standard therapy.One reviewer found that the lab tests (CPT code 83520 and 8352059) were not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in neurology with subspecialty certification in pain management and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology with subspecialty certification in neuromuscular medicine 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for the Autonomic Nervous Function Testing - autonomic reflex screen (CPT 95924) and Endopat study (CPT 95923). The autonomic nervous system is responsible for various functions including heart rate, body temperature, breathing, digestion, and sensation. The autonomic nervous system is composed of the sympathetic and parasympathetic nervous systems and their interplay. Disease occurs when there is the parasympathetic and sympathetic are unbalance or when there is direct damage to the autonomic nervous system in various disease states. Some symptoms linked to autonomic nervous system disease is dizziness, sweating abnormalities, and loss of appetite. The autonomic system can be evaluated using several tests including tilt table test, monitor of heart rate and blood pressure during specific situations, gastric emptying studies, quantitative sudomotor, axon reflex test, thermoregulatory sweat test, and urodynamics. Based on the medical literature, there is limited data showing that autonomic nervous function testing provides patients with improved health outcomes when compared to standard modalities for evaluation in this clinical setting. Thus, the Autonomic Nervous Function Testing - autonomic reflex screen (CPT 95924) and Endopat study (CPT 95923) provided were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the Autonomic Nervous Function Testing - autonomic reflex screen (CPT 95924) and Endopat study (CPT 95923) provided were 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 Autonomic Nervous Function Testing - autonomic reflex screen (CPT 95924) and Endopat study (CPT 95923) provided were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An  enrollee has requested authorization and coverage for facial feminization surgeries including terino malar shell implants; genial advancement; subnasal lip lift; a Kenalog injection to the forehead; and neck lift. The World Professional Association for Transgender Health (WPATH) has stated that medically necessary gender affirming/confirming surgical procedures include certain facial plastic reconstruction. The WPATH further states that the medical procedures that are attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. The Transgender Medicine Model NCD Working Group has also explained that other surgeries or procedures that may be necessary to resolve gender dysphoria and allow transgender women to navigate the world as women include reconstructive facial feminization surgery. These procedures are not cosmetic; rather, they serve a reconstructive purpose for transgender women whose overall physical appearance otherwise prevents them from being perceived as female. In this case, the submitted records reflect that the patient has a documented history of gender dysphoria. The patient has been on cross-gender hormone therapy and has had other gender confirming surgeries, and her gender dysphoria has not been alleviated by these other treatments. While the surgeon and primary care provider do not clearly state how the requested procedures will address the patients gender dysphoria, a letter from the patients psychologist is convincing. The psychologist attests at length and with emphasis how the facial feminization surgery is needed to therapeutically treat the patients gender dysphoria and relieve the patients distress. Under these circumstances, the requested facial feminization surgeries are medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested procedures are medically necessary for treatment of the patients behavioral health 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for high-intensity focused ultrasound (HIFU).Findings:  Three physician reviewers found HIFU has been increasingly used for the treatment of localized prostate cancer within the last decade. It has the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity. Potential candidates are patients with low to moderate risk prostate cancer. The available literature mainly consists of prospective case series and retrospective studies showing short term to intermediate term outcomes for localized prostate cancer. There is a lack of controlled trials available for analysis, and there is a lack of long-term survival data. American Urological Association/American Society of Radiation Oncology/Society of Urologic Oncology guidelines note clinicians should inform low-risk prostate cancer patients who are considering focal therapy or HIFU that these interventions are not standard care options because comparative outcome evidence is lacking. Therefore, HIFU was not likely to have been superior over other treatment options. 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 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 coverage for Vytorin tablets. Based on the records provided, the patient presents with increased coronary risk but no clinical obstructive coronary disease. In this circumstance, guidelines for the evaluation and management of hyperlipidemia are established and endorsed by several national organizations. These guidelines indicate that if the patient is not at goal LDL reduction despite maximal tolerated statin medications, then consideration of adding ezetimibe is reasonable and appropriate. Ezetimibe is the generic equivalent of Zetia and as such should have the same efficacy and side effect profile as Zetia contained within Vytorin. The use of Vytorin is not medically necessary in this case since the available generic equivalent is equally effective. Therefore, the requested Vytorin tablets are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested Vytorin tablets are not medically necessary for the treatment of this patient.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Case Summary: The patient has a visually significant cataract in the left eye. The surgeon removed the cataract and used the femtosecond laser as part of the procedure. The surgery was successful. At issue in this case is whether the eye surgery at issue was medically necessary for treatment of the patients medical condition.MD Analysis: There is no question that the patient needed to have cataract surgery to improve her vision. Therefore, performing cataract surgery with intraocular lens implant was medically necessary. The remaining question is whether using the femtosecond laser was medically necessary. The femotosecond laser is used to perform some parts of the procedure including creating the incision; correcting astigmatism; making an opening in the capsule; and to partly breaking up the cataract into smaller pieces. However, the same steps can be performed manually using standard cataract surgery techniques and to date nearly all studies have shown the results to be equivalent. In this particular case, the surgeon has not provided any evidence to indicate why a femtosecond laser was medically necessary. Specifically, why surgery could not be performed using standard manual technique.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 partially overturned.Credentials/Qualifications: The reviewer is board certified in ophthalmologyand 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.