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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for authorization and coverage for implantation of a Vagus Nerve Stimulation (VNS) Therapy System. The U.S. Food and Drug Administration (FDA) approved the use of the VNS Therapy System in 2005 as a device/treatment modality for the treatment of a refractory episode of major depressive disorder. Current medical literature supports the use of VNS as a pathway for adjunctive and alternate treatment for severe, recurrent, refractory major depressive disorder, and as safe and effective in the long-term. In this case, the submitted records document that the patient meets the criteria for a diagnosis of major depressive disorder, and that the refractory designation of the condition, having completed 12 treatment sessions of ECT without remission of symptoms. Therefore, implantation of a VNS Therapy System 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 authorization and coverage for implantation of a Vagus Nerve Stimulation (VNS) Therapy System 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 psychiatry 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept procedure (CPT 22899 and HCPCS C9752  intraosseous basivertebral nerve ablation).Findings:  The physician reviewer found that Intracept procedure involves radiofrequency ablation of the basivertebral nerve for the treatment of patients with chronic low back pain. The U.S. Food and Drug Administration (FDA) has approved the Intracept procedure for the following specific indications: 1. chronic low back pain of greater than six months duration; 2. failure to respond to other nonsurgical treatments for six months; and 3. magnetic resonance imaging (MRI)-demonstrated Modic changes in at least one vertebral endplate at one or more levels from L3 to S1. The SMART trial by Fischgrund and colleagues was a prospective, randomized, sham controlled, double-blinded trial. The authors reported that at 24- and 60-month follow-up, patients demonstrated continued significant improvement in primary outcome measures when compared to their pretreatment condition. Khalil and colleagues performed an open-label, randomized, controlled trial of the Intracept procedure versus standard conservative therapy. As noted by the authors, the study was terminated early due to significant improvements in all outcome measures with Intracept versus standard therapy. On review of the available documentation, this patient meets the requirements for the Intracept procedure on the basis of the chronicity of his symptoms, failure of numerous other therapies, and imaging evidence of Modic changes at L4-5 and L5-S1. The patient has no documented contraindications to the procedure, and he has attempted treatment with some conservative strategies. All told, the requested Intracept procedure (CPT 22899 and HCPCS C9752  intraosseous basivertebral nerve ablation) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested Intracept procedure (CPT 22899 and HCPCS C9752  intraosseous basivertebral nerve ablation) 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in neurological surgery and is actively practicing. Physician reviewer 2 is board certified in neurological surgery and is actively practicing. Physician reviewer 3 is board certified in neurological surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for electrostimulation biofeedback physiotherapy (a total of six one-hour sessions). Electrostimulation biofeedback physiotherapy is a pelvic floor rehabilitation technique that is well supported in current medical literature for the treatment of urinary/fecal incontinence, pelvic pain, erectile dysfunction, defecatory disorders, and dyssynergic defecation. These techniques are largely designed to increase the internal urethral and rectal sphincter tone to avoid incontinence. Researchers report that biofeedback is an effective therapy for defecatory disorders and for constipation with dyssynergic defecation. The authors note that biofeedback therapy is a mainstay of management of common anorectal disorders, including fecal incontinence, functional anorectal pain, and functional defecation disorders. In this case, the records note that the patient has constipation as a result of the increased sphincter tone and a diagnosis of pelvic floor dyssynergia. The patient reports an inability to engage in rectal sexual activity due to his condition. In this clinical setting, the requested services are medically indicated. Therefore, electrostimulation biofeedback physiotherapy (a total of six one-hour sessions) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Supartz injection series in the right knee. Findings: Per the medical literature, although viscosupplementation may relieve knee 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 has tried and failed other conservative treatments, including arthroscopic surgery, physical therapy, NSAIDs, and corticosteroid injections, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Supartz injection series in the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for Gelsyn-3 injections in the right knee. Per the medical literature, although viscosupplementation may relieve knee 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 has a history of chronic right knee pain that has worsened due to her weight gain over the past year. Due to the mild nature of the osteoarthritis, the patient is not a candidate for joint replacement. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Gelsyn-3 injections in the right knee 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 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: The patient has requested reimbursement for all or any of the 30 sessions of TMS treatment provided by Manish Sheth, M.D., of Achieve TMS Centers. Current medical literature supports the use of TMS for severe, recurrent major depressive disorder that is unresponsive to medication management and psychotherapy treatment. Medical literatures note that multiple randomized controlled trials and published literature have supported the safety and efficacy of TMS antidepressant therapy in the treatment of major depressive disorder. Likewise, TMS is supported for the treatment of OCD that has not responded to other traditional treatments. The U.S. Food and Drug Administration (FDA) approves the use of the Brainsway Deep TMS System for the treatment of adult patients suffering from Obsessive-Compulsive Disorder. In a systematic review, researchers found that TMS was superior to sham stimulation for the amelioration of OCD symptoms. In this case, the records demonstrate that the patient has refractory OCD that has failed treatment with psychotherapy and medication management. Given that TMS was the clear next step in the treatment of this patients refractory OCD, the services at issue were medically indicated. In this patients case, TMS treatment was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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. Therefore, 30 sessions of TMS treatment provided by Manish Sheth, M.D., of Achieve TMS Centers were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) a quantitative electroencephalography (qEEG), (2) a neurofeedback of a qEEG, (3) a neurotransmitter test, and (4) an adrenal stress test. A qEEG is a modern type of electroencephalography (EEG) analysis that involves recording digital EEG signals which are processed, transformed, and analyzed using complex mathematical algorithms. While studies have shown some distinctive forms of electrical activity in various conditions such as ADHD, schizophrenia, depression, and obsessive-compulsive disorder, the clinical conclusion of such distinctive patterns is unclear and do not as of yet render durable recommendations in changes of management and/or outcome. Neurofeedback of a qEEG is a treatment including components such as reinforcement, coaching, and direct feedback on brain activity, in particular electrical brain activity. Krepel and colleagues report that in a sample of 114 patients with ADHD, response rates were 85% with greater or equal to 25% reduction, 70% with greater or equal to 50% reduction, and 55% with remission. While Coben and colleagues note that the use of qEEG guided neurofeedback shows promise as an emerging treatment for various diagnoses including ADHD, seizure disorders, learning disabilities, and symptoms associated with autism spectrum disorder, there is a lack of evidence supporting a benefit of qEEG for this patients conditions. Regarding neurotransmitter testing, while differences may be detected from person to person, its clinical application is limited at best, and there is a lack of data in current medical literature supporting the use and/or the association of improved outcomes of neurotransmitter testing in evaluating patients with gastrointestinal complaints. Adrenal states may also vary from individual to individual. From a neurological perspective, such variations identified by testing are of limited clinical neurological benefit. There is a lack of data that such information would alter outcomes and/or management of a patient. Therefore, (1) a qEEG, (2) a neurofeedback of a qEEG, (3) a neurotransmitter test, and (4) an adrenal stress test are not medically necessary for the evaluation of this patient..Final Result: The reviewer determined that the requested/at issue 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 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 Rituxan (rituximab 1000 mg every two weeks). Sharp and colleagues explain that connective tissue disease-associated interstitial lung disease often fails to respond to conventional immunomodulatory agents. In examining the results of 24 patients with interstitial lung disease patients treated with rituximab after failing to improve with standard therapy, the authors reported that lung imaging remained stable or improved for 11 patients, while worsening was observed in nine patients. The authors found that decline in forced vital capacity (FVC) improved following rituximab treatment, while diffusion capacity of carbon monoxide was stable. The authors concluded that rituximab is a therapeutic option in treatment-refractory connective tissue disease-associated interstitial lung disease. Similarly, in evaluating ten patients with connective tissue disease-associated interstitial lung disease, Fitzgerald and colleagues noted a statistically significant improvement following rituximab therapy in pulmonary function, with a mean increase of 19% in diffusing capacity of the lungs for carbon monoxide (DLCO), and a mean increase of 13% in FVC. The authors concluded that treatment with rituximab resulted in an objective, measurable improvement in pulmonary function and/or radiological severity in patients with connective tissue disease-associated interstitial lung disease, and that the improvements in pulmonary function were statistically significant despite the small number of study participants. In a systematic review, Bellan and colleagues reported that overall agreement existed concerning the effectiveness of rituximab in the stabilization of lung disease, with some studies reporting an improvement of functional parameters from baseline. Given that current medical literature supports the use of the requested medication in this patients clinical setting of undifferentiated connective tissue disease-associated interstitial lung disease, the requested medication is medically indicated. Therefore, Rituxan (rituximab 1000 mg every two weeks) is 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 sub-specialty certification in rheumatology 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 hyperbaric oxygen therapy (CPT 99183 and HCPCS G0277) for 30 total treatments of 90 minutes (four segments per treatment) once daily for five (5) days per week. The submitted documentation supports the medical necessity of a portion of the services at issue. Hyperbaric oxygen therapy has been approved by the U.S. Food and Drug Administration for treating sudden hearing loss. The American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline on sudden hearing loss listed hyperbaric oxygen therapy, in conjunction with steroid therapy, as an option for either initial or salvage therapy, depending on the timing of symptomatic onset. In this case, hyperbaric oxygen therapy was initiated five days after symptom onset, so it would be classified as initial therapy. The patient received oral steroids and three intratympanic injections of steroids as well, with the oral steroids and the first injection received prior to hyperbaric oxygen therapy initiation. There is moderate peer-reviewed evidence to support limited use of hyperbaric oxygen therapy in combination with steroids as initial therapy for idiopathic sudden sensorineural hearing loss. Researchers concluded that there was no significant difference in hearing gain between patients with idiopathic sudden sensorineural hearing loss treated with intratympanic steroids/hyperbaric oxygen therapy and those treated only with intratympanic steroids. Researchers did find a benefit for patients treated with intratympanic steroids/hyperbaric oxygen therapy in combination, with a stronger effect in those with severe to profound sudden sensorineural hearing loss, such as this patient. Researchers noted that there is no universally accepted hyperbaric oxygen therapy protocol with proven effectiveness, although a 10-day to 20-day treatment duration (90-minute session each day) has been recommended by the Undersea and Hyperbaric Medical Society. Therefore, a 20-session hyperbaric oxygen therapy course was and is medically necessary to treat the patients hearing loss. Final Result: The reviewer determined that a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: An enrollee has requested reimbursement for two Durolane injections (HCPCS J7318) in the right knee.Current medical literature pertaining to viscosupplemention 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, arthroscopic surgery and a cortisone injection were not beneficial, and the only alternative was a total knee arthroplasty. Accordingly, the two Durolane injections (HCPCS J7318) in the right 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 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.