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 DecisionDx-Melanoma genetic testing. The National Comprehensive Cancer Network (NCCN) guidelines recommendation for treatment of a stage 1a melanoma is wide local excision. In this case, the patients melanoma, Breslow depth of 0.45 mm, was clinically stage 1A, without high-risk features such as ulceration. The DecisionDx-Melanoma result classified her risk of recurrence as Class 1a, the lowest risk of recurrence at five years. Given that the patients melanoma was superficial without high risk features, pathologic staging procedures may have been used for prognostication, and the results of the testing did not affect the course of the patients treatment. Therefore, the DecisionDx-Melanoma genetic testing was not likely to have been more beneficial than any other available standard therapy for the patients medical condition.Findings:  Three of the three physician reviewers found the requested DecisionDx-Melanoma genetic testing was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service was not likely to have been 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 dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a consultation with a neuropsychiatrist with a board certification in psychiatry and neurology. There is evidence that a neuropsychiatric evaluation is warranted in traumatic brain injury (TBI) cases. Campbell noted that, Neuropsychiatrists evaluate patients with neurological disorders and general medical conditions who are experiencing psychiatric symptoms. Knowledge of functional neuroanatomy of the central nervous system is essential to offer accurate diagnoses and treatments. This patients records document that she has undergone treatment with a neurologist for the diagnosis of mild TBI with cognitive and speech issues possibly exacerbated by untreated depression and anxiety. There is further report that the patient underwent a prior neuropsychiatric evaluation. The medical literature recommends a neuropsychiatric evaluation in patients with TBI but does not specify that the specialist performing such an evaluation needs to hold board certifications in both neurology and psychiatry. A qualified neurologist with experience in treating patients with TBI can address the neurologic aspects of TBI, and a separate provider with background in either psychology or psychiatry can focus on the patients mood disorders that arise out of TBI. For these reasons, the requested consultation with a neuropsychiatrist with a board certification in psychiatry and neurology is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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 with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for Contour Next One Meter, Contour Next Test Strips, and Microlet Lancets. This patients recent hemoglobin A1C was 5.8. The patient is currently on Metformin XR and Metformin. His provider has recommended use of Contour Next One Meter, Contour Next Test Strips, and Microlet Lancets. One study from Harashima and colleagues reported that self-monitoring of blood glucose (SMBG) levels is helpful to maintain glycemic control in non-insulin-treated type 2 diabetes. The authors concluded that their findings support improved hemoglobin A1C levels in patients with continued SMBG compared to patients who discontinued SMBG for management of type 2 diabetes. A number of glucometers are available which may aid in SMBG. Moreover, medical literature noted that among the current blood glucose monitoring systems, the Contour Next Meter demonstrates excellent accuracy. Therefore, the requested Contour Next One Meter, Contour Next Test Strips, and Microlet Lancets are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 diabetes, endocrinology, and metabolism 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 patients parent has requested reimbursement and prospective authorization and coverage for Nutropin AQ Nuspin. Findings: Based on the available documentation, this patient meets the standard of care criteria for growth hormone therapy based on two failed growth hormone standard provocative tests, prior growth velocity below the 10th percentile for age and gender tracked over at least one year, delayed bone age, and appropriate GH dosing. Although the patients height is just above the third percentile, their growth pattern persists below the 10th percentile which may fall below the familial pattern. A six-month trial of growth hormone therapy is warranted to assess the patients clinical response. All told, Nutropin AQ Nuspin was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and 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 pediatrics with subspecialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet-rich plasma injections (CPT 0232T).Findings:  The physician reviewer found that based on the available evidence, patients undergoing meniscal repair with platelet-rich plasma augmentation experience similar clinical outcomes at midterm follow-up when compared with conventional meniscal repair. However, additional studies are needed to determine the efficacy of meniscal repair augmented with platelet-rich plasma. Shahid and Kundra concluded that there is some evidence to support the utility of platelet-rich plasma for selected indications in osteoarthritis, ligament, tendon and meniscal injuries of the knee. The authors cautioned that before widespread use can be recommended, high-quality prospective randomized studies are required. Belk and colleagues reported that there are a limited number of high-quality studies comparing outcomes and healing rates between patients undergoing meniscal repair with versus without platelet-rich plasma augmentation. This patient sustained a radial tear of the lateral meniscus. She underwent right knee arthroscopic lateral meniscus repair on 5/13/20. In the post-operative period, two platelet-rich plasma injections were performed to the right knee. The provider indicated that these injections were performed to maximize the biologic healing potential of this complex tear. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of platelet-rich plasma for this patient. Therefore, the platelet-rich plasma injections (CPT 0232T) were not 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 platelet-rich plasma injections (CPT 0232T) were 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Privigen x 2 (split dose over two days) 50 grams each day and Actemra 680 mg every four weeks. Based on the available documentation, this patient presents with biopsy proven B cell-mediated rejection status post kidney transplant in 2016 due to end-stage renal disease. Treatment has included intravenous immunoglobulin (IVIG), Actemra, tacrolimus, and belatacept. Given the ongoing concern for rejection, her provider has recommended an additional course of IVIG followed by monthly Actemra for six doses. Per Choi and colleagues, significant reducing donor specific antibodies (DSAs) has been demonstrated to improve long-term outcomes in patients with antibody-mediated rejection. The authors noted that the development of DSAs post-transplantation leads to chronic antibody-mediated rejection and transplant glomerulopathy. The authors found that Actemra-treated patients demonstrated graft survival and patient survival rates of 80% and 61% at six years, respectively. Moreover, there is support for use of IVIG in this patients clinical setting. For these reasons, the requested Privigen x 2 (split dose over two days) 50 grams each day and Actemra 680 mg every four weeks are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in nephrology 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 bilateral reduction mammaplasty. The American Society of Plastic Surgeons (ASPS) states that reduction mammaplasty is supported for patients with severe symptoms of macromastia and evidence of reduced health-related quality of life. This patient presents with upper back, neck and shoulder pain. She has clinical findings of shoulder grooving from bra straps documented on physical examination. The patient reports intertrigo underneath her breasts, but the records do not support that the intertrigo has been unresponsive to medical management. She reports headaches, but this is not specific to breast hypertrophy in the absence of further clinical information. On review, this patient has severe symptoms of macromastia and at least two decreased quality of life signs. Per ASPS criteria, the requested bilateral reduction mammaplasty is medically necessary for 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; (2) to create a normal appearance, to the extent possible. The available records support the presence of bilateral breast hypertrophy, which is a developmental deformity. The provider noted that the patients condition is causing pain, which is impairing the patients ability to function. The appearance of ptotic breasts is within normal limits for the patients age and weight. The California reconstructive surgery statute supports the requested bilateral reduction mammaplasty for this patient due to the presence of a developmental deformity that is causing her functional impairment. Accordingly, the requested bilateral reduction mammaplasty is reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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 Standup Magnetic Resonance Imaging (MRI) scan. Findings:  The physician reviewer found that Symptoms related to the low back are very common, especially in older individuals. The American College of Radiology (ACR) has attempted to provide guidelines for physicians encountering various common patient presentations. Under their guidelines for acute low back pain without red flags, MRI is clearly stated to be, Usually not appropriate. For chronic low back pain, without complications, the ACR characterizes MRI of the spine without contrast material as, Usually not appropriate. In elderly individuals, there is some allowance, but the ACR actually states that CT is preferred. In addition, findings on MRI do not necessarily correlate with symptoms. A patient may have incidental findings on an MRI that are not symptomatic, and, conversely, may have relatively unimpressive findings on MRI but may be experiencing significant symptoms. Regarding the request for Standup Magnetic Resonance Imaging (MRI), as distinguished from routine supine MRI, there is no inherent reason why upright MRI is not justifiable in some situations.As in all cases, the only reason to proceed to imaging studies is if it will change management of the patient. In this case, there is no indication that the patient is being considered for surgery, and there is no indication that the patient has any red flag signs of motor or sensory deficits. Under these circumstances, without additional clinical findings, it is unlikely that a surgical procedure is appropriate, and a conservative approach is typically warranted. Therefore, the requested Standup Magnetic Resonance Imaging (MRI) scan is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar epidural steroid injection.Epidural steroid injections have a clinically established role in the short-term management of low back pain when the following two criteria are met: the pain is associated with symptoms of nerve root irritation and/or low back pain due to disc extrusions and/or contained herniations; and the pain is unresponsive to conservative treatment, including but not limited to pharmacotherapy, exercise or physical therapy. Kreiner and colleagues evaluated the role of epidural spine injection for the treatment of lumbar disc herniation with radiculopathy. They concluded that transforaminal epidural spine injection is recommended to provide short-term (24 weeks) pain relief in a proportion of patients with lumbar disc herniations with radiculopathy. The American Society of Interventional Pain Physicians concluded in their last published guidelines in 2013 that, for lumbar disc herniation with radiculitis, the evidence is considered good for short-term and long-term relief with local anesthetics with steroids. Evidence is superior in contained disc herniation. In a follow-up statement, they reiterated that the evidence is good for caudal epidural, interlaminar epidural, and transforaminal epidural injections with or without steroids in managing disc herniation or radiculitis. In this case, while the patient reports chronic low back pain, the submitted medical records from her neurosurgeon, neurologist and internal medicine providers do not show an assessment and diagnosis of lumbar radiculitis. The records show evaluation for chronic neck pain. Furthermore, while there is a referral from the neurosurgeon to a pain management specialist for consideration of lumbar epidural steroid injection, there is no clinical evaluation or context for this referral. Under these circumstances, the requested lumbar epidural steroid injection is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections (J0585 Injection, onabotulinumtoxinA).The American Headache Society (AHS) recommends preventive treatment when attacks significantly interfere with patients daily routines despite acute treatment, a patient has four or more attacks per month, or a patient has contraindication to, failure, or overuse of acute treatment. Four injectable preventive therapies are available in the United States including onabotulinumtoxinA (Botox). OnabotulinumtoxinA is approved for chronic migraine. The lack of need for slow dose escalation, the rapid onset of therapeutic benefits, and the favorable tolerability profiles are advantages that injectable therapies have in common. American Academy of Neurology (AAN) guidelines recommend Botulinum toxin A for the management of chronic migraine, defined as attacks lasting 4 or more hours on at least 15 days each month for 3 months. Botulinum toxin A is established as effective and should be offered to increase headache-free days in chronic migraine. Frampton and colleagues conducted a review of data and concluded that the totality of evidence from clinical trials and real-world studies indicates that onabotulinumtoxinA (Botox) is an effective and generally well tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics.In this case, the patient has a history of chronic migraines that have not responded to multiple oral preventative medications. Based on the AHS statement, AAN guideline and study noted above, the patient is a candidate for prophylactic treatment with Botulinum toxin therapy. The patient has also experienced clinical improvement with Botulinum toxin therapy. Under these circumstances, the requested Botox injections (J0585 Injection, onabotulinumtoxinA) are medically necessary to treat the patients chronic headaches.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology 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.