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 a FoundationOne CDx genetic testing assay.Findings: Two out of three physician reviewers found that the FoundationOne CDx genetic testing assay at issue was likely to have been more beneficial than any other available standard treatments for the patients medical condition.In all cases, the genetic mutations that are present with pancreatic cancer can provide prognostic significance and can help direct therapy. Mutational analysis is part of the algorithms that are included within the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for pancreatic cancer. According to the NCCN guidelines, germline testing is recommended for any patient with confirmed pancreatic cancer, using comprehensive gene panels for hereditary cancer syndromes. The guidelines recommend genetic counseling for patients who test positive for a pathogenic mutation or for patients with a positive family history of cancer, especially pancreatic cancer, regardless of mutation status. For example, BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. NCCN guidelines also state that tumor/somatic gene profiling is recommended for patients with locally advanced/metastatic disease who are candidates for anti-cancer therapy to identify uncommon mutations. The guidelines state that providers should consider specifically testing for actionable somatic findings including, but not limited to fusions (ALK, NRG1, and TRK, ROS1), mutations (BRAF, BRCA1/2, HER2, KRAS, PALB2), and mismatch repair (MMR) deficiency. All of these genes were available on the FoundationOne test. In this case, the results from molecular profiling offered the patient the ability to make a rational selection of their next treatment regimen. Therefore, the FoundationOne CDx genetic testing assay at issue was likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in medical oncology, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 authorization and coverage for one 60-minute speech therapy session per week for six months. This patient presents with autism spectrum disorder with associated severe expressive and receptive language delays, with severe impairment of articulation. The patients provider has recommended one 60-minute speech therapy session a week to address specific goals. Per the California Health and Safety Code section 1374(a)(3)(A), Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. On review of the available documentation, the requested speech therapy services are in accordance with the generally accepted standards of mental health care, clinically appropriate in terms of type, frequency, and duration, and are not primarily for the economic benefit or convenience of the provider or patient (Zwaigenbaum, et al.; Mulhern, et al.; Baumer and Spence). The patient has demonstrated limited progress in his articulation skills during the last evaluation period, but he was also noted to have transitioned to telehealth during the pandemic. As noted in the medical literature, children with autism spectrum disorder frequently have difficulty participating in telehealth therapy. Moreover, data is emerging on the increased stress around therapeutic service disruption in families of children with autism spectrum disorder due to the pandemic (Manning, et al.). Despite his transition to telehealth, the patient has continued to make progress in his expressive and receptive language skills, as reported by his parents and provider, and as demonstrated by improved age equivalency scores on his PLS-5 scores. All told, the requested one 60-minute speech therapy session per week for six months is medically necessary for treatment of the 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 neurology with special qualification in child 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mavyret 100-40 mg three tablets per day for eight weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions. The patient's genotype could not be determined and the patient does not have cirrhosis and is reported to be to treatment-naive. Mavyret is effective for all genotypes of hepatitis C, and Mavyret for eight weeks is a first-line recommended regimen for non-cirrhotic patients with all genotypes of hepatitis C based on the results of a series of trials. Therefore, the genotype is not needed to determine which treatment regimen is appropriate for this patient, or whether the patient should be treated. Early treatment is warranted per the AASLD. Additionally, a study determined untreated hepatitis C can have several serious or devastating consequences, including the development of cirrhosis, hepatocellular carcinoma, lymphoma, cryoglobulinemia, and renal disease. For these reasons, the requested Mavyret 100-40 mg three tablets per day for eight weeks is supported as medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Orthovisc vials purchased and injected in the left knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, there is a history of lasting relief from prior injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments as well as arthroscopic surgery, with the alternative being a total knee arthroplasty. Under these circumstances, the Orthovisc vials purchased and injected into the left knee were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for daily injections of human growth hormone (somatropin). Growth Hormone Deficiency (GHD) is a medical condition in which the body does not produce enough growth hormone (GH). A study recognized effects which include reduced muscle mass and strength, reduced bone strength and osteoporosis, decreased energy levels, impaired concentration and loss of memory, increased body fat, lipid abnormalities, and insulin resistance. Another study found GHD is also appreciated to be a factor in increased mortality from cardiovascular disease. Growth hormone replacement therapy can provide a number of measurable benefits to GH-deficient adults. These include improved bone density, increased muscle mass, decrease of adipose tissue, faster hair and nail growth, strengthened immune system, increased circulatory system, and improved blood lipid levels. An additional study found that in patients with known hypothalamic or pituitary disease, doctors can establish the diagnosis of growth hormone deficiency with high sensitivity and specificity when there are 3 or 4 additional pituitary hormonal deficiencies or a sub-normal IGF-1 level. To establish the diagnosis in patients without these criteria requires provocative growth hormone stimulation. In this case, this patient does not have a documented history of growth hormone deficiency and does not meet the criteria for diagnosing growth hormone deficiency. Endocrinology progress notes state that while the patient had a recent IGF-1 level that was low, his previous levels were normal. Progress notes indicate that it is possible that the patients obesity and other comorbidities may be causing a decrease in his IGF-1 rather than overt growth hormone deficiency or hypopituitarism. Under these circumstances, the requested daily injections of human growth hormone (somatropin) are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are 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 internal medicine, with subspecialty certification in endocrinology, diabetes 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 patient has requested authorization and coverage for an InCourage high frequency chest wall oscillation device. Researchers note that respiratory care is of the utmost importance in caring for patients with neuromuscular disease because it is a major determinant of quality of life and survival. In this case, the patient has neuromuscular diaphragmatic weakness from spinocerebellar ataxia, a progressive disease with a high risk for poor pulmonary clearance, mucous retention, and secondary pulmonary infections. She has tried and failed mucous clearance programs including manual chest physical therapy and flutter valves. In this clinical setting, the requested device is medically indicated to optimize mucous clearance, improve pulmonary hygiene, and minimize the risk of pulmonary infections. Therefore, an InCourage high frequency chest wall oscillation device is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 sub-specialty in pulmonary disease and critical care 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 bilateral facet joint injections at L2-3, L3-4 and L4-5. Most chronic back pain patients have both disc and facet joint disease. Findings:  The physician reviewer found that the patient most likely obtains relief of his radicular pain due to discogenic disease and stenosis from epidural injections, and he obtains axial back pain relief from facet joint injections. Per the guidelines, facet joint injections can be performed on a maximum of three levels in one sitting. Repeat facet joint injections may be appropriate if there is 50% improvement. In this patients case, he has a history of greater than 50% benefit from prior facet joint injections. Additionally, recent physical therapy has not been beneficial. Thus, there is sufficient support for the requested services in this clinical setting. Therefore, bilateral facet joint injections at L2-3, L3-4 and L4-5 are 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 anesthesiology 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 reimbursement and prospective authorization and coverage for brand name Ventolin HFA Aerosol Solution. The U.S. Food and Drug Administration (FDA) has approved Ventolin HFA for the treatment of patients with asthma. Moreover, the Global Initiative for Asthma (GINA) reported on the safety and efficacy of Ventolin HFA as demonstrated in the medical literature. Based on the available records, this patient has tried and failed at least one generic alterative to brand name Ventolin HFA Aerosol Solution. The provider charted that the patient has responded well to treatment with brand name Ventolin HFA. Therefore, the brand name Ventolin HFA Aerosol Solution 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 internal medicine with subspecialty certifications in pulmonary disease and critical care 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 Euflexxa injection series (J7323) in both knees. Evidence from systematic reviews and randomized controlled trials support that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient reportedly experienced substantial relief from prior Euflexxa injections on multiple occasions. Furthermore, the patients remaining treatment options are limited. The patient has tried and failed other conservative treatments including non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy, with the alternative being surgery. For these reasons, the requested Euflexxa injection series (J7323) in both knees is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cranioplasty.Following decompressive hemicraniectomy, a cranioplasty is an indicated, standard of care surgical procedure performed to re-establish cranial protection of the brain, restore cranial cosmesis, improve cerebrospinal fluid (CSF) dynamics, and to avoid or correct conditions like the syndrome of the trephined. Extensive research has been performed to understand the timing of cranioplasty and the potential risks and benefits of early versus late cranioplasty. Some data suggests that early cranioplasty (i.e., within 3 months) may be associated with improved neurological recovery, although it may be associated with increased complications.In this case, the patients medical condition is an acquired large skull defect that is the result of a life-saving hemicraniectomy performed in the setting of an apparent large right middle cerebral artery stroke. The patient has survived, and there is no indication in the submitted documentation that the patient has an extremely short life expectancy (i.e., days to weeks). Cranioplasty is a medically necessary surgical procedure in a patient with anything other than a very brief life expectancy. The timing and nature of said procedure is left to the neurosurgeon performing it based on optimization of the patients medical comorbidities, the status of the incision and the underlying brain tissue, the presence or absence of hydrocephalus, the availability of the patients own cranial bone or the need for a prosthesis. Accordingly, the requested cranioplasty is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurological 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 enrollees parent has requested authorization and coverage for implantation of a Watchman left atrial appendage closure (CPT 33340) device, including a one-day inpatient hospital stay. In the PREVAIL trial, Holmes and colleagues reported that left atrial appendage occlusion was noninferior to warfarin for stroke prevention. In a meta-analysis report of left atrial appendage closure (LAAC) versus systemic therapy with warfarin for prevention of stroke, systemic embolism, and cardiovascular death, Holmes and colleagues reported that LAAC resulted in improved rates of hemorrhagic stroke, cardiovascular/unexplained death, and nonprocedural bleeding compared to warfarin. In this case, given the patients recurrent gastrointestinal bleeding, the requested service is likely to be more beneficial when compared to no anticoagulation or reinitiating long-term anticoagulation. Therefore, implantation of a Watchman left atrial appendage closure (CPT 33340) device, including a one-day inpatient hospital stay is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested implantation of a Watchman left atrial appendage closure (CPT 33340) device, including a one-day inpatient hospital stay 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 service 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.