Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for spinal surgery (CPT Codes 22614, 22612, 22558, and 22585). Updated guidelines by Eck and colleagues for lumbar fusion in situations of back pain without stenosis or spondylolisthesis note that inherent to such situations is the inability to identify the source of patients' pain. They conclude that under these circumstances the best evidence supports that a comprehensive rehabilitation program is as effective as lumbar fusion. These guidelines recommend lumbar fusion only for patients who fail conservative care. In the same series of practice guidelines, Resnick and colleagues conclude that lumbar fusion is an appropriate treatment option for lumbar stenosis with spondylolisthesis. Yavin and colleagues also conclude that fusion is most efficacious in patients with spondylolisthesis. In other situations, the risk benefit ratio requires meaningful caution to be observed.In this case, there is a major discrepancy between what is interpreted on the patient's imaging studies by the surgeon and the radiologist. In the setting of a major discrepancy in the radiology interpretation, it is difficult to discern the etiology of the patient's pain. Based on the submitted documentation, it is not clear exactly what pathology is present in the patient's lumbar spine. As noted above, lumbar fusion has been found to be an appropriate treatment option for lumbar stenosis with spondylolisthesis, however, there are limited to no data in the submitted records that reflects that these pathologies are present in this case. Therefore, there is insufficient evidence on imaging to suggest that there is pathology that warrants the requested spinal surgery. In addition, there is no documentation in the submitted records that the patient has attempted an aggressive non-surgical rehabilitation that includes physical therapy to treat her symptoms since her fusion surgery. Exhaustive non-surgical strategies do not appear to have been performed since the patients surgery. Furthermore, there is no evidence of spinal instability present to suggest that additional fusion surgery is required at this time. Under these circumstances, the requested spinal surgery (CPT Codes 22614, 22612, 22558, and 22585) is not medically necessary to treat this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat this patients medical condition. Therefore, the Health Plans denial should be upheld.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant CDx test (circulating tumor DNA test). Metastatic colon cancers should be tested for KRAS, NRAS, BRAF, HER2, and microsatellite instability (MSI) or mismatch repair (MMR). The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of colon cancer notes that such testing may be performed individually or as part of next-generation sequencing (NGS) panel. NGS panels may identify rare and actionable mutations and fusions known to have targeted therapy. Universal genetic testing is recommended on all colon cancer tumors, and an NGS panel allows for initial screening with MSI testing. However, cell-free/circulating tumor DNA testing should not be used instead of a histologic tissue diagnosis. Standards for analytical performance characteristics of cell-free tumor DNA have not been established, and in contrast to tissue-based testing, no guidelines exist regarding the recommended performance characteristics of this type of testing. The use of cell-free tumor DNA testing in colon cancer is not as well studied, unlike in the setting of non-small cell lung cancer. In this clinical setting, it is unclear how the results of such testing would change the course of the patients management given that the patients molecular markers had previously been evaluated. Therefore, the Guardant CDx test (circulating tumor DNA test) was not likely to have been more beneficial for evaluation of the patient's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Guardant CDx test (circulating tumor DNA test) at issue 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 service at issue 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Genetic testing (Oncology (prostate) gene expression profile by real-time polymerase chain reaction (RT-PCR) of three genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score). This patient presents with elevated prostate specific antigen (PSA) and benign prostatic hyperplasia (BPH). The patient underwent ExoDx testing, which revealed a 91% chance of no high grade prostate cancer. As noted in the peer-reviewed medical literature, the use of ExoDx testing to forego biopsy in patients with increasing PSA and negative magnetic resonance imaging (MRI) has not been demonstrated to improve clinical patient health outcomes. Additionally, the use of ExoDx to forego biopsy and treat patients with benign prostatic hyperplasia (BPH) without biopsy in rising PSA, has not been shown to provide improved predictive value over MRI alone. For these reasons, the genetic testing (Oncology (prostate) gene expression profile by real-time polymerase chain reaction (RT-PCR) of three genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the genetic testing (Oncology (prostate) gene expression profile by real-time polymerase chain reaction (RT-PCR) of three genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in urology and is actively practicing. Physician reviewer 2 is board certified in urology and is actively practicing. Physician reviewer 3 is board certified in urology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for all and/or any of (immunoassay for interleukin-13; interleukin-10; interleukin-4; and interleukin-5). Researchers note that the general approach to diagnosis of food allergy include modalities such as a detailed medical history, physical examination, elimination diets, skin prick tests, allergenspecific serum immunoglobulin E (IgE) measurements, and oral food challenges. Current medical literature does not support the use of blood tests evaluating the levels of interleukins as part of the evaluation or treatment of food allergies, and do not document a proven benefit from such tests. Rather, the treatment of food allergies is either through strict avoidance of the food or oral immunotherapy under the care of an allergist. Therefore,  (immunoassay for interleukin-13; interleukin-10; interleukin-4; and interleukin-5) was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the CPT 83520 (immunoassay for interleukin-13; interleukin-10; interleukin-4; and interleukin-5) provided by Foundation Labs was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue 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 is board certified in in internal medicine and in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is certified in in allergy and immunology and in pediatrics 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bioidentical hormone pellet therapy. Findings:  The physician reviewer found that there is a lack of evidence in current medical literature on the efficacy, safety, or adverse effects of bioidentical hormone pellet therapy, which are custom-compounded, multihormone regimens with dose adjustments based upon serial hormone monitoring. Pinkerton and Constantine note that more research on the efficacy, safety, and consistency of compounded hormone therapy that is not approved by the U.S. Food and Drug Administration (FDA) for treatment of menopausal symptoms is needed. The Endocrine Society reports that there is no rationale for routine prescribing of unregulated, untested, and potentially harmful custom-compounded bioidentical hormone therapies. In this case, the requested medication is not likely to be more beneficial than traditional hormone replacement therapy or conservative measures. Therefore, bioidentical hormone pellet therapy is not 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 (bioidentical hormone pellet therapy is 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 requested medication is 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 obstetrics and gynecology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for testosterone cypionate (200 mg/mL x 12-30DS). The records provided for review document that this patient has a history of hypogonadism complicated by obstructive sleep apnea (OSA). The patients provider states that treatment with continuous positive airway pressure (CPAP) has been effective in improving the patients OSA, but the patient's testosterone levels remain low. The provider has recommended continued treatment with testosterone cypionate since it has been beneficial for the patient. Testosterone deficiency can be asymptomatic or lead to a broad spectrum of symptoms ranging from sexual symptoms to nonspecific symptoms, such as fatigue, depression, poor concentration, altered body composition with more body fat and decreased muscle mass, and lower bone mineral density (Ide, et al.). The mainstay of a diagnosis of hypogonadism includes the presence of signs and symptoms consistent with hypogonadism coupled with low morning serum testosterone levels on two or more occasions (Salonia, et al.). The management of testosterone deficiency aims to induce and maintain secondary sex characteristics and correct symptoms of testosterone deficiency. The potential benefits of therapy include increased libido, improved sexual function, improved mood and well-being, and increased muscle mass and bone density (Petering, et al.). In this case, the patients records support a diagnosis of hypogonadism that has responded well to treatment with testosterone cypionate. For these reasons, the requested testosterone cypionate (200 mg/mL x 12-30DS) is 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Euflexxa injection to the left shoulder. Per the medical literature, although viscosupplementation may relieve shoulder pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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, the patient is a 45-year-old male severe osteoarthritis of the left shoulder confirmed on X-rays and MRI. The records note that the patient has tried and failed cortisone injections. The patient has reported benefit from viscosupplementation on two occasions, with the benefits from the first injection lasting seven months and the benefits from the second injection lasting four to five months. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, an Euflexxa injection to the left shoulder is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
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 Privigen [intravenous immunoglobulin (IVIG)]. In a review paper on the clinical approach to the diagnosis of autoimmune encephalitis in children, Cellucci and colleagues report that behavioral changes, such as repetitive or stereotypical behaviors, irritability, hyperactivity, hypersexuality, insomnia and anger outbursts, are common in pediatric autoimmune encephalitis. Psychiatric symptoms may range from mood swings and mild personality changes to fulminant psychosis and occur in over 50% of autoimmune encephalitis patients. New-onset psychosis in children younger than 13 years of age is uncommon and considered a red flag for an underlying medical, rather than primary psychiatric, condition. The authors further note that the onset of symptoms in autoimmune encephalitis is typically of rapid onset and persist without therapy, in contrast to pediatric acute-onset neuropsychiatric syndrome (PANS) patients, who often experience a relapsing-remitting course. In a cohort study of 21 children with moderate to severe PANS, Melamed evaluated the efficacy of IVIG over a period of six months (six infusions) based on mean changes in psychological evaluation scores using six different assessments, including the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), Clinical Global Impression of Severity, and the Parent-Rated Pediatric Acute Neuropsychiatric Symptom Scale (PANS Scale). The authors concluded that their results demonstrated statistically significant reductions in symptoms from baseline to end of treatment in all six assessments measured. In this case, the records note that the patient had an abrupt onset of severe psychiatric symptoms. She responded poorly to previous therapies, including multiple psychotropic medications, antibiotics, steroids and non-steroidal medication. She underwent an appropriate diagnostic workup, including a normal brain MRI and 24-hour EEG. The records noted positive titers for mycoplasma and pneumococcus. The patient reported some improvement in her psychiatric symptoms following two infusions of IVIG, which were separated by over a year, an atypical regimen for administration. Given the refractory nature of this patients course, and previous documented response to IVIG, the requested services are medically indicated. Therefore, Privigen (IVIG) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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 patients parent has requested reimbursement and prospective authorization and coverage for (1) Tacrolimus ointment 0.1% and (2) Tacrolimus ointment 0.1%. Elmets and colleagues note that psoriasis is a chronic condition and that topical medications are the most common agents in the treatment of mild to moderate psoriasis. The authors further note that in a study of 167 patients with facial and intertriginous psoriasis, treatment with tacrolimus 0.1% resulted in clearing for 65% of patients after eight weeks of therapy. Given that topical therapy is often the first-line treatment for limited areas of involvement, especially in children, due to safety concerns with systemic drugs in this population, the medication at issue was medically indicated. Therefore, (1) Tacrolimus ointment and (2) Tacrolimus ointment 0.1% was and is medically necessary for the 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 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for an anterior spinal instrumentation without fusion surgery. Current medical literature demonstrates the ability of spinal tethering technique for the treatment of adolescent idiopathic scoliosis to correct curves without fusion. Hoernschemeyer and colleagues report in a retrospective review of two year to five year postoperative results of 31 patients that anterior vertebral body tethering may be a reliable treatment option for adolescent scoliosis in skeletally immature individuals with higher success rates and lower revision rates. In a study of 17 patients, Newton and colleagues report that 13 of the 17 patients were able to avoid fusion with the use of anterior spinal growth tethering. The evidence shows that the requested procedure has a track record of at least five years and allows for the avoidance of standard long fusion segments in a high percentage of these cases. Therefore, anterior spinal instrumentation without fusion surgery is likely to be more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested anterior spinal instrumentation without fusion surgery 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.