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 Rezum transurethral destruction of prostate tissue (CPT/HCPCS codes 53854, 96372, and J1885). This patient presented with a diagnosis of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. He has failed conservative treatment with medical BPH management. He underwent further work-up, which revealed a prostate size less than 80 grams and presence of a median lobe. BPH is non-cancerous enlargement of the prostate which often causes urinary obstruction leading to lower urinary tract symptoms of weak stream, frequency and nocturia. Treatment begins with medical management including alpha blockers, 5-alpha reductase inhibitors, or a phosphodiesterase inhibitor. Patients with significant frequency and urgency may also be treated with antimuscarinics like oxybutynin or the beta-3 agonist Myrbetriq. When patients fail, or do not tolerate medical management, they frequently proceed to surgical treatments to improve their urinary symptoms. Surgical treatments for BPH include transurethral resection of the prostate, which has been associated with significant side effects. In an effort to reduce patient morbidity, more minimally invasive techniques are being developed. The minimally invasive Rezum system utilizes convective radiofrequency water vapor thermal therapy. The U.S. Food and Drug Administration (FDA) approved the Rezum device in 2015. The advantage of the Rezum system is the use of convective heat energy rather than tissue ablation. A prospective, blinded, randomized controlled trial demonstrated improvements in urinary quality of life scores and urinary flow rates that were durable through three years of follow-up with minimal adverse outcomes (Gupta, et al.). In addition, the use of Rezum for the treatment of refractory urinary symptoms from BPH is supported as a treatment option in the most recent American Urological Association (AUA) treatment guidelines, including the 2019 and 2020 updates, and is now considered standard practice within the urologic community (Foster, et al.; Parsons, et al.). Given this support, the Rezum transurethral destruction of prostate tissue (CPT/HCPCS codes 53854, 96372, and J1885) was 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 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for arthroscopy with femoroplasty and labral repair (CPT codes 29914 and 29916). This patient presented with left groin pain after a motor vehicle accident that was rated moderate to severe and did not resolve with three months of conservative treatment. Imaging revealed CAM type femoroacetabular impingement with a pistol grip type deformity. She did not have osteoarthritis or other contraindication to surgery. She underwent arthroscopy of the hip and was found to have chondrolabral separation with wave sign in zone II and zone III of the acetabulum that was repaired with suture anchors. In addition, there was a CAM type impingement that was corrected. The provider noted the presence of a pistol grip deformity of the proximal femur, which is known to be a cause of osteoarthritis, and starts as a tilt deformity and progresses to the pistol grip, then eventually cam-type femoroacetabular impingement. A review of the literature pertaining to CAM type femoroacetabular impingement reveals appropriate indications for surgery were present in this patients case. Moreover, the operative procedure of femoroplasty, and labral repair was appropriate for management of the left hip pain with labral tear and femoroacetabular impingement of the patient. All told, the left hip arthroscopy with femoroplasty and labral repair (CPT codes 29914 and 29916) was 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. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cabometyx tablet 60 mg and 40 mg for a total of 100 mg. Soft tissue sarcomas are a diverse group of cancers that comprise over 50 different histologic subtypes (Linch, et al.). Alveolar soft part sarcoma has a pathognomonic translocation that can lead to the production of pro-angiogenic factors, which provide the basis for anti-angiogenic therapy. This patient was treated with sunitinib with progression of disease. His provider has recommended treatment with Cabometyx, which is a multi-function tyrosine kinase inhibitor. The U.S. Food and Drug Administration (FDA) has approved Cabometyx for the treatment of progressive metastatic medullary thyroid cancer. Several small studies have shown activity of Cabometyx against soft tissue sarcomas (Schoffski, et al.; Chuk, et al.). Based on the available medical evidence and this patients progression while on sunitinib, treatment with Cabometyx is indicated. Based on the FDA approved dose for adults of 140 mg per day, and this patients documented weight of 99 kg, 100 mg daily is consistent with current guidelines. For these reasons, the requested Cabometyx tablet 60 mg and 40 mg for a total of 100 mg is 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 Cabometyx tablet 60 mg and 40 mg for a total of 100 mg is 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 medication is 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 reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: An enrollee has requested reimbursement and authorization and coverage for continued skilled nursing facility services.Spinal decompression surgery is generally known to be more effective than conservative care for the treatment of lumbar spinal stenosis that causes pain and neurological dysfunction. Postoperatively, multidisciplinary rehabilitation plays a significant role in the restoration of function and community reintegration.In this case, the submitted documentation reflects that the patient has had significant overall dysfunction since her spinal decompression surgery. Records reflect that the patient made only modest to minimal progress over many weeks of multidisciplinary rehabilitation. The patient continued to require minimum assistance for her transfers and she plateaued with respect to ambulation at the minimum assistance level for household distances. The patient was otherwise independent with wheelchair mobility. Records indicate that she continued to require moderate to maximal assistance for lower body self-care. There was no clear plan in the submitted documentation concerning how the patient would be realistically and safely reintegrated into the community. There was also no indication in the patients medical records that she is reasonably expected to progress to a fully independent level, given the magnitude of her functional deficits and her lack of significant progress to date. There were otherwise no other skilled nursing or medical needs requiring ongoing inpatient level care. Under these circumstances, continued skilled nursing facility services were not, and are not, medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary for treatment of the patient's 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for acute inpatient physical and occupational rehabilitation services. This patient had extensive spinal revision surgery from the cervical to the pelvic levels. This was complicated postoperatively by neurological weakness in his legs, surgical wound dehiscence requiring wound clean out with revision wound closure, and diverticulitis with perforation requiring colectomy and colostomy. He was nonambulatory postoperatively. He has undergone extensive rehabilitation but has plateaued functionally. Barriers to further progress included severe cognitive and behavioral deficits and neurological weakness in the lower limbs. Despite extensive rehabilitation, he continues to require moderate to maximum assistance for slide board transfers. He has otherwise improved with supervision in propelling his wheelchair, which is the maximum level of function expected given his cognitive deficits. While there are intermittent symptoms and clinical issues that arise due to his chronic conditions, there are no ongoing therapy goals requiring acute inpatient rehabilitation level services. Therefore, acute inpatient physical and occupational rehabilitation services were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement and prospective authorization and coverage for food tolerance induction program services (CPT 95044 and 95018) and 22 future dates of services. Oral immunotherapy has not been recommended as a standard care for treatment of food allergies by the American Academy of Allergy Asthma and Immunology (AAAAI) guidelines due to uncertainty whether therapeutic benefit outweighs risk of treatment. Although some studies have reported potential benefits, according to the AAAAI, the safety and efficacy of oral immunotherapy has not been established as superior to allergen avoidance. Furthermore, oral immunotherapy is associated with a higher rate of systemic adverse events compared with other forms of immunotherapy as well as a minor risk of eosinophilic esophagitis. Oral immunotherapy has not been recommended as a standard of care to provide for patients with food allergies (Nowak-Wegryzn, et al.). For this patients food allergies, the standard of care remains food avoidance and availability of an epinephrine autoinjector. Given these findings, the food tolerance induction program services (CPT 95044 and 95018) and 22 future dates of services were not and are 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 food tolerance induction program services (CPT 95044 and 95018) and 22 future dates of services were not and are 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 services at issue were not and 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 allergy and  immunology with subspecialty certification in pediatrics and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and  immunology 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 Xeljanz XR tablets. Findings: According to guidelines, for patients with continued disease activity despite treatment with disease modifying anti-rheumatic drug (DMARD) monotherapy, combination of traditional DMARD agents, addition of a tumor necrosis factor (TNF) inhibitor or non-TNF biologic, are supported rather than continuing DMARD monotherapy. In this case, the patient was previously treated with the DMARD methotrexate. Subsequently, this patient received Xeljanz to optimize disease control. Based on the ACR recommendations, the use of Xeljanz for treatment of this patients rheumatoid arthritis is medically appropriate after DMARD therapy with methotrexate was unsuccessful. Furthermore, the guideline specifically stipulates that there is no particular order of preference when choosing the next agent to optimize rheumatoid arthritis disease control after attempting use of a DMARD. Given this support, the requested Xeljanz XR 11 mg tablets are 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. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genetic testing. This patient has a personal history of bilateral upper lobe pulmonary emboli and a family history of breast cancer, blood disorder, and malignant melanoma. The patients provider has recommended genetic testing to determine the presence of mutations in diagnosing and treating the patient. As noted in the medical literature, patients with inherited thrombophilia have a genetic tendency for venous thrombosis. The most common inherited thrombophilias are the factor V Leiden (FVL) mutation and the prothrombin gene mutation (PGM), which together account for up to 60% of cases of an inherited hypercoagulable state. Homozygosity for methylenetetrahydrofolate reductase (MTHFR) polymorphisms is a relatively common cause of mildly elevated plasma homocysteine levels, but these mutations do not appear to increase the risk of venous thromboembolism in women. High quality studies have not found a significant increase in venous thromboembolism risk among patients homozygous for MTHFR polymorphisms. Routine screening for inherited thrombophilias is not recommended due to the low frequency of the condition becoming symptomatic and the lack of a safe long-term method of prophylaxis against thromboembolism. All told, the requested genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the genetic testing is not likely to be more beneficial for evaluation of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are 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: Physician reviewer 1 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 2 is board certified in genetics and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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: An enrollee has requested reimbursement for air and ground ambulance transportation services.Functional impairments due to traumatically acquired brain insults can be profound, particularly in the setting of severe injuries and in the setting of intracerebral hemorrhage. Traumatic brain injury, notably, is a major cause of disability in adults. While there is some natural recovery following acute traumatic brain injury, the impairments associated with this condition, nevertheless, are also generally amenable, at least in part, to various rehabilitation interventions. Formal rehabilitation in a setting that is appropriate for the patients level of dysfunction and clinical needs is the standard of care for this condition.In this case, the patient sustained a well-documented, severe, acute traumatic brain injury. He received emergency and critical care services in the immediate and early aftermath of the injury. The patient was then transferred to a long-term acute care hospital for further acute hospital level management. He was eventually stabilized sufficiently for rehabilitation-focused care. Due to the severity of his deficits and the intensity of his rehabilitative needs, he did require inpatient rehabilitation services. There was, however, no medical necessity of a transfer of the patient by air ambulance from the acute hospital in the Sacramento, California area to an out-of-state rehabilitation facility. This was not the closest facility that could have provided appropriate care for the patient. There are multiple appropriate facilities in the northern California area. Notably, San Francisco, California, a major U.S. metropolitan area with multiple major medical and rehabilitation centers, is in close proximity to Sacramento, California, and in the range of ground ambulances/transportation. The original disposition plan when the patient was at the out-of-state rehabilitation center, in fact, was a lateral transfer to an acute inpatient rehabilitation facility in his home state of California for further care. There was therefore no medical necessity of the transfer of the patient by air ambulance from the out-of-state rehabilitation center back to California. The need for this non-emergent transportation was solely the consequence of a medically unnecessary transfer of the patient from his home state of California. Accordingly, the air and ground ambulance transportation services at issue were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyperbaric oxygen therapy (G0277). Francis and Baynosa noted that hyperbaric oxygen has demonstrated utility in the salvage of compromised grafts or flaps and can increase the likelihood and effective size of composite graft survival, improve skin graft outcomes, and enhance flap survival. Bennett and colleagues have found that hyperbaric oxygen therapy may be used to treat cancer survivors who experience late radiation tissue injury. In this case, the patient has a chronic non-healing wound that was exacerbated by cancer recurrence, surgery, and prior radiation. Although she previously underwent hyperbaric oxygen therapy, the wound has worsened and may require flap surgery. Based on current medical literature, hyperbaric oxygen therapy is medically indicated to prepare for a flap or graft, and when there is evidence of significant soft tissue damage related to radiation. Therefore, hyperbaric oxygen therapy (G0277) is medically necessary for the 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 family medicine with sub-specialty certification in undersea and hyperbaric 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.