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

Nature of Statutory Criteria/Case Summary: Trastuzumab (Herceptin) is an antibody directed at cancer cells that overexpress the HER2 gene. Herceptin has been demonstrated to be useful with chemotherapy in the treatment of breast cancer, and have minimal efficacy in the treatment of gastroesophageal cancer. However, there is a paucity of data showing the long-term safety and efficacy of Herceptin in duodenal cancer. In the peer-reviewed medical literature, it was reported on an excellent response of duodenal cancer to FOLFOX with Herceptin. Despite this report, there was no control group to confirm the response was due to the addition of Herceptin. In duodenal cancer, there is a lack of data to demonstrate the usefulness of Herceptin, either with chemotherapy or as a single agent. Accordingly, Herceptin is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.One reviewer found that Herceptin is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is 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 medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgical preparation of graft side of trunk by excision of scar (CPT code 15002), with the approved surgery to repair trunk (CPT 13101 and 13102).  Findings:  The physician reviewer found that the patient complained of severe pain and tension in the pubic area resulting in back pain. The patient reported a rash that was treated successfully with medication and improved hygiene. The enrollee reported flattening of the mons pubis area and distortion of the labia. The provider noted that the panniculectomy scars could be revised and relieve some tension from the mons pubis. The provider stated the patient could benefit from excision of the vertical abdominal scar and recreation of the umbilicus.Under California law, reconstructive surgery means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to improve function or create a normal appearance, to the extent possible. If the surgery is intended to create a normal appearance, it must offer more than a minimal improvement in appearance. California law also defines cosmetic surgery as surgery that is performed to alter or reshape normal structures of the body in order to improve appearance. California law mandates that health plans must cover reconstructive surgery but are not required to cover cosmetic surgery. The documentation provided for review does not include evidence of complaints of pain or loss of function from the scar. Moreover, the proposed recreation of the umbilicus would not be reconstructive in nature. The proposed procedure is not for correction of any physical symptom and would be performed solely to enhance the patients appearance in the absence of any signs or symptoms of functional abnormalities. The clinical documentation and photographs demonstrate that this patient has a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. All told, the requested surgical preparation of graft side of trunk by excision of scar (CPT code 15002) is not medically necessary or reconstructive in nature 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the medication Xifaxan 550mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients irritable bowel syndrome with diarrhea (IBS-D) and small intestinal bacterial overgrowth. The submitted documentation supports the medical necessity of the requested medication. In this case, the patient had both irritable bowel syndrome, diarrhea-predominant (IBS-D), and small intestinal bacterial overgrowth. The patient had failed both Lomotil and tetracycline. The formulary alternatives for IBS-D would not treat the patients bacterial overgrowth, and formulary alternative antibiotics are associated with adverse effects and would not treat the patients IBS-D. Under these circumstances, the Xifaxan 550mg tablets were medically necessary to treat the patients medical condition.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient presented for a physical therapy evaluation on 7/29/18.  The records indicated difficulty with ambulation due to pain and fatigue. The patient ambulates short distances inside the home using a four-wheeled walker with a seat. She lives with relatives in a wheelchair-accessible single level home, and does not spend time alone in the home. The records noted that she has a group 2 power wheelchair in good mechanical condition, which she uses intermittently in the home and to access an outdoor mailbox. She has adequate support to assist with shopping and transportation to medical appointments. On examination, the patient was noted to be obese with active range of motion in the upper and lower extremities within functional limits. She is independent for transfers and toileting.  The patient requires assistance for bathing and dressing tasks. Her standing balance is impaired and she ambulates with an antalgic gait between 10 and 20 feet with use of a walker. Physical examination on 8/29/18 demonstrated normal findings in the respiratory and cardiovascular systems, and no extremity edema. There were no documented neurological deficits. The patient has requested authorization and coverage for an electric wheelchair or a power scooter. The Health Plan has denied this request and reported that the requested equipment is not medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. The provider observed that the patient ambulates with a walker, but the records do not document significant cardiovascular, respiratory, musculoskeletal, or neurological impairment. A physical therapy mobility evaluation indicated that the patient has functional range of motion and strength in the limbs and she is able to transfer independently. She has an antalgic gait but is otherwise able to ambulate short distances with a walker. She has a functioning group 2 power wheelchair. The patient desires a portable scooter or electric wheelchair that can be disassembled (by someone other than herself) for transport. The records do not indicate that the patient has impairments that would preclude her from using a walker or properly fitted manual wheelchair to accomplish mobility-related activities of daily living. Therefore, the requested electric wheelchair or a power scooter are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient presented to her primary care provider. The records noted a growing skin lesion on the upper left back. This lesion had been present for approximately one year, has gradually increased in size, and has been bleeding intermittently. The provider noted that the patient is fair skinned with multiple freckles. There was no personal history of skin cancer noted. The records noted basal cell carcinoma. The treatment plan included the performance of Mohs micrographic surgery to the left scapular back. The patient has requested authorization and coverage for Mohs micrographic surgery. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of the requested services. The standard of care for basal cell carcinoma is typically local destruction or surgical removal, including electrodessication and curettage, elliptical excision, or Mohs micrographic surgery. Small, well-circumscribed or superficial tumors may be treated with cryotherapy, photodynamic therapy, or topical anti-tumor medication. In selected patients, radiation, including external beam radiation or brachytherapy, is an appropriate and effective option. In this case, based on the truncal location, nodular (rather infiltrative) type of basal cell carcinoma, and its size smaller than one centimeter, the requested Mohs micrographic surgery is not medically necessary for the treatment of this patient. 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 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: A patient with a medical history significant for human immunodeficiency virus (HIV), chronic throat pain, difficulty breathing through the nose, and significant snoring has requested tonsillectomy and adenoid surgery. Findings:  The physician reviewer found that Radiographic imaging revealed significant findings. The patient has been diagnosed with tonsillar and adenoid hypertrophy. The symptoms have persisted, despite treatment with antibiotic therapy. The plan of care includes a tonsillectomy and adenoid surgery. The Health Plan indicates that the requested treatment is not medically necessary for the patients medical condition and has denied coverage.Tonsillar and adenoid hypertrophy is a common finding and a frequent cause of obstructive sleep apnea (OSA) in the HIV positive patient population (Epstein). Knox showed that 11 of 12 patients with HIV and large adenoids and tonsils had obstructive sleep apnea. Owens and Hicks reported data demonstrating that OSA is common among patients living with HIV. In this case, the adenoid is obstructing the patients ability to breathe through his nose. The tonsils are noted as 3+ by his provider and 4+ per the patient. This patient with HIV presents with tonsillary hypertrophy and symptoms of presumptive OSA including snoring and disordered sleep breathing. He failed to respond to antibiotic therapy. 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 otolaryngology 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 positron emission tomography/computed tomography (PET/CT). As noted in the medical literature, PET/CT has been proven to be more sensitive in the detection of recurrent and residual disease in patients with head and neck squamous cell carcinoma. Since PET/CT is better able to visualize the complexity of the anatomic area and the alteration of normal tissues related to therapy. Most protocols recommend a PET/CT be performed of the neck and chest 8-12 weeks after the final chemotherapy treatment. This patient reportedly completed chemotherapy in August 2018 and no follow-up imaging has been reported. All told, the requested PET/CT is medically necessary for further evaluation of this patients medical condition. 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 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 acupuncture. The records document that this patient experiences headaches. Although she experienced mild improvement with medication, the patient presented secondary effects, therefore the medication was discontinued. The available medical evidence suggests that adding acupuncture to symptomatic treatment of attacks reduces the frequency of headaches. In addition, the authors noted that there is consistent evidence that acupuncture provides additional benefit to treatment of acute migraine attacks only or to routine care. Moreover, researchers found that acupuncture exhibits certain efficacy both in the treatment and prevention of migraines, which is superior to no treatment, sham acupuncture and medication. Further, acupuncture enhanced the quality of life more than did medication. Given this support and the transformation of this patients migraine headaches, an acupuncture trial of eight sessions is supported as medically necessary. 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 oriental 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: The patient has requested authorization and coverage for a magnetic resonance imaging (MRI) of the lower extremity without contrast. The records provided for review document that this patient has knee pain associated with objective evidence of swelling over the tibial tunnel site two years after an ACL reconstruction and partial medial meniscectomy. The pain is relatively severe warranting a diagnostic work-up. The provider has recommended an MRI scan. The recent medical literature supports an indication for an MRI for persistent knee pain following prior surgery. MRI is the preferred modality for imaging the knee to show soft tissue as well as bone pathology and guide patient management and treatment. Knee pain two years after a torn meniscus and ACL reconstruction requires MRI to make an accurate diagnosis. Diverse knee pathology, multiple pain sources and complex anatomy, as well as the possibility of recurrent meniscal tears and graft related issues, need to be ruled out. The MRI knee protocol and sequences should ensure detection of both soft tissue and osseous structures in detail and with accuracy. Therefore, a MRI of the lower extremity without contrast is medically necessary for evaluation and management of this patients postoperative knee pain and swelling.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (Oncotype DX).Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. The National Comprehensive Cancer Network (NCCN) recommends Oncotype DX testing for men with low-risk or favorable intermediate-risk disease. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Patients with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. In sum, the gene test (Oncotype DX) was likely to have been superior over 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

An enrollee has requested authorization and coverage for a colonoscopy. The submitted documentation supports the requested services in this patients case. Although not routinely recommended for the evaluation of constipation, the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that colonoscopy may be done once to rule out disease, especially if symptoms are unresponsive to therapy, as in this case. ASGE guidelines for the evaluation of constipation state that colonoscopy should be considered in selected patients to exclude obstruction from cancer, stricture, and extrinsic compression. Colonoscopy is useful to assess for organic causes of constipation.  This would be useful in this clinical setting, as laxatives at a normal dose have been ineffective. Therefore, the requested colonoscopy is medically necessary for the 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 internal medicine with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma injection.Findings:  Two of the three physician reviewers found that the medical evidence has not established the superior effectiveness of the requested services in this patients case. There is a lack of high-quality clinical evidence supporting the efficacy of platelet-rich plasma injections in this clinical setting. There is insufficient evidence to support the use of platelet-rich plasma injections for treating musculoskeletal soft tissue injuries. The authors noted that there is a need for standardization of platelet-rich plasma injection preparation methods. In this case, platelet-rich plasma injections are not recommended as first-line treatment for the patients elbow condition. There is some lower quality evidence supporting a single injection as a second-line treatment following failed attempts at physical therapy with eccentric loading stretching and strengthening exercises. The submitted documentation does not indicate a failure of such a trial. Therefore, the requested platelet-rich plasma injection is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested services 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 reviewers 1, 2 and 3 are board certified in orthopedic 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.