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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral breast ultrasounds.Medical literature supports breast ultrasound as an augmentation to routine mammography. When a lump or suspicious abnormality is discovered on routine mammography, a targeted breast sonogram is the next step prior to biopsy. The issue, however, is that automated whole breast sonography is performed as an adjunct to mammography, not as a replacement. Berg and colleagues have demonstrated an increased detection rate of occult breast cancer in a screening population when sonography is added to routine mammography. Whether one uses an automated mechanism or simply scans the entire breast, the issue is still whether breast sonography is adequate as a solitary screening test for breast cancer. Kaplan states that automated breast ultrasonography is a developing technology that has been recently approved by the U.S. Food and Drug Administration for use in screening for breast cancer as an adjunct to mammography. There are limitations for any type of sonography in evaluating breasts. Specifically, automated whole breast ultrasounds cannot diagnose microcalcifications, and is marginal in evaluating the deeper portions of the breast. In this case, the referring practitioner has requested only breast sonography as a screening procedure. However, whole breast sonography is not a replacement for mammography and should be used in addition to a mammography. Therefore, the requested bilateral breast ultrasounds are not medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for the evaluation of 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for biofeedback therapy. Rao and Patcharatrakul note that dyssynergic defecation is common and affects up to one-half of patients with chronic constipation. The authors further note that biofeedback therapy is recommended as the first-line of treatment for dyssynergic defecation. Lee and colleagues report that patients with abnormal contractions of the puborectalis muscle seem to respond favorably to biofeedback treatment. Wald and colleagues found that biofeedback training protocols designed to correct dyssynergia and inadequate rectal propulsion were shown in three randomized controlled trials to significantly improve the ability to evacuate the rectum. In this case, the patient has symptoms and test results consistent with constipation due to dyssynergic defecation. She has failed multiple medical therapies, including advanced laxatives such as Linzess. In this clinical setting, the requested service is medically indicated. Therefore, biofeedback therapy 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin.Findings: The U.S. Food and Drug Administration (FDA) has approved somatotropin to treat idiopathic short stature (ISS), defined as standing height below -2.25 SDs without identifiable cause. Standard of pediatric endocrine care for suspected growth disorders includes brain magnetic resonance imaging (MRI) with and without gadolinium contrast and standard provocative testing for endogenous growth hormone release. In this case, the patient has not met the FDA-approved indications or generally accepted indications for somatotropin. The patient displays normal height and appropriate growth velocity for mid-puberty. Additionally, the patients pubertal timing, pubertal tempo, and predicted adult height are consistent with her familial patterns. Moreover, there are no records of brain magnetic resonance imaging or any standard provocative test for endogenous growth hormone release. Therefore, Nutropin AQ NuSpin is not medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in 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 qualitative or semiquantitative immunoassay testing (CPT 86352) provided by Moleculera Labs, Inc. The records provided for review document that this patient has undergone treatment with one medication trial, Sertraline, for management of his obsessive-compulsive disorder (OCD) and anxiety. Per the medical literature and The International College of Obsessive-Compulsive Spectrum Disorders, there is a lack of data to support a clinical role for the Cunningham Panel, as performed in this patients evaluation for treatment planning. In the medical literature, Hesselmark and Bejerot concluded that, clinical use of the Cunningham Panel in diagnosing PANS or PANDAS [pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS)] is not supported by this study. Moreover, this patients records do not document medication adjustment or change of behavioral approaches to support testing for medication management. All told, the qualitative or semiquantitative immunoassay testing (CPT 86352) provided by Moleculera Labs, Inc. 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 qualitative or semiquantitative immunoassay testing (CPT 86352) provided by Moleculera Labs, Inc. 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for continued in-home private duty nursing services for 86 hours per week. Home based nursing services are essential for the parents of young patients with life-limiting or life-threatening diseases who spend an average of nearly nine hours per day managing the patients basic healthcare needs such as personal hygiene and feeding, administering drugs and managing symptoms like seizures, pain, and sleep related problems during the night. Current data shows that the number of medical appliances and the status of single caregivers correlated proportionally with a greater amount of time needed for the patients care. It is important for these families to receive appropriate support with daily care, through the evaluation of individual needs of the patient and organization of care models. Based on the evidence from research, the time spent providing care is associated with the number of medical appliances used at home. The records provided for review fail to document that this patient has experienced worsening respiratory function, hospitalizations, recurrent aspiration pneumonia, or complications from posterior secretions. The provider did not document that the patient has required use of any life sustaining medical devices. Overall, the records indicate that the patients medical conditions have been stable. As such, there is a lack of clinical rationale provided for continuation of 86 hours per week of in-home nursing care for treatment of this patient. Therefore, the requested continued in-home private duty nursing services for 86 hours per week are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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 an osteogenesis stimulator.A review of the literature pertaining to electrical stimulation for osteogenesis of a pars interarticularis defect reveals this to be a viable option. electrical stimulation has long been used for healing of fracture non-unions. a computational model showed that electrical stimulation facilitated bone restoration by stimulating osteoblasts. Further, a study that found that electrical stimulation showed some effectiveness in intercollegiate athletes who had acute lumbar spondylolysis. In this case, the patient was found to have a pars interarticularis fracture on the left side after a hemilaminectomy at L4-5. Therefore, an osteogenesis stimulator is medically necessary for the treatment of the patients medical condition.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 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 Xifaxan (550 mg three times a day for 14 days with two refills). The records provided for review document that this patient has irritable bowel syndrome, diarrhea-predominant (IBS-D) and gastroesophageal reflux disease (GERD). The patient reportedly experienced symptomatic improvement with Xifaxan. Her provider has recommended a repeat course of treatment with Xifaxan. Per Pimentel and colleagues, Xifaxan has been demonstrated to be safe and effective for the treatment of IBS-D. The U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D with repeat courses if needed, and the medication has proven safe and effective in randomized placebo-controlled trials for IBS-D (Schoenfeld, et al.). In the TARGET-3 trial, over 1,000 patients with IBS were treated with Xifaxan 550 mg three times daily with significant symptomatic improvement (Lembo, et al.). The American College of Gastroenterology (ACG) guidelines for the treatment of irritable bowel syndrome state that Xifaxan is an effective medication (Ford, et al.). In this case, the patient experienced a satisfactory response to Xifaxan, with recurrence of symptoms. Xifaxan has been demonstrated to be effective with repeat treatment courses. For these reasons, the requested Xifaxan (550 mg three times a day for 14 days with two refills) is supported as 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. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a wearable monitor by Lifewatch services. Albers and colleagues note that the diagnosis of cryptogenic stroke is a diagnosis of exclusion and may include extensive testing and that recent data from devices capable of continuous arrhythmia monitoring suggest that even brief episodes of atrial fibrillation (AF) may increase the risk of stroke. The authors further note that monitoring systems detect brief, rare episodes of AF in patients with stroke may include external, ambulatory, patch, and real-time continuous attended cardiac systems. Gladstone and colleagues note that early detection and treatment of AF, a preventable cause of recurrent stroke, are critical. In this case, the patient is age 40. Radiology notes reported findings consistent with left middle cerebral artery (MCA) stroke consistent with nonocclusive thrombus. The records showed that an extensive workup for structural heart disease, cerebrovascular disease, and a hypercoagulable state did not reveal an etiology. For this patient, a finding of occult AF would have marked clinical significance resulting in the need for long-term anticoagulation in the setting of a prior embolic stroke, and extended ambulatory monitoring was used to assess for occult AF. Given that asymptomatic paroxysmal AF remains a significant concern in patients with cryptogenic stroke, the use of the device at issue was appropriate to provide prolonged cardiac monitoring to elucidate AF and the cause of the embolic event. Therefore, the wearable monitor by Lifewatch services was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the wearable monitor by Lifewatch services at issue was 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 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 overturned. Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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 Aimovig. Findings: The U.S. Food and Drug Administration (FDA) has approved Aimovig for the treatment of patients with migraine. A study found that Aimovig reduced the number of monthly migraine days in patients with chronic migraine compared to patients treated with placebo. The authors concluded that Aimovig is a potential therapy for the treatment of patients with migraine. Another study found that, significantly reduced migraine frequency, the effects of migraines on daily activities, and the use of acute migraine-specific medication over a period of six months. The records provided for review document that this patient has failed treatment with multiple medications including topiramate, amitriptyline, and Imitrex. There are no contraindications to Aimovig evident in the patients medical history. All told, the requested Aimovig 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. Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in vascular 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraosseous ablation of the basivertebral nerve with the Intracept procedure. The guidelines published from the International Society for the Advancement of Spine Surgery noted that intraosseous basivertebral nerve ablation for the treatment of chronic low back pain is a treatment option for patients with clinical and radiologic findings supporting a vertebrogenic source of back pain. Randomized controlled trials have reported statistically significant pain scores and functional improvements over a two year period with use of the Intracept procedure (Khalil, et al.; Lorio, et al.; Fischgrund, et al.). This patients clinical and radiologic findings of Modic type changes at L5 support a vertebrogenic cause of back pain. The patient has not experienced substantial relief from comprehensive and multimodal treatment options. Chronic use of opioids is not indicated for the treatment of chronic low back pain. Radiofrequency ablation of the basivertebral nerve is the indicated as the next step in the treatment algorithm and is likely to provide functional relief to the patient. Therefore, the requested intraosseous ablation of the basivertebral nerve with the Intracept procedure is 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 requested intraosseous ablation of the basivertebral nerve with the Intracept procedure 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 reviewers 1, 2, and 3 are board certified in anesthesiology with subspecialty certification in pain management 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 trigger point injections. The records document that this patient is undergoing treatment for occipital neuralgia, chronic migraine without aura, and neck pain. The provider reports that the patient has tried and failed multiple medications including antidepressants, anticonvulsants, beta blockers, triptans, and NSAIDs. The medical records note that the patient previously underwent occipital nerve blocks with reduction in symptoms. However, there is a lack of documentation that the patient has been treated with trigger point injections in the past. A progress note stated the patient would benefit from tendon injections especially for their neck pain and migraine attacks. The provider did not report that these injections were performed. The current medical literature and guidelines suggest that trigger point injections are appropriate as adjunct therapy in the treatment of headache disorders with the presence of active trigger points on physical examination. With regard to the request for trigger point injections in the context of migraines and occipital neuralgia, Madore and colleagues noted that, the addition of trigger point injections did not lead to a significant increase in length of benefit over occipital nerve blocks alone. Similarly, Krel and Mathew concluded that, there is limited efficacy data regarding trigger point injections. All told, the current request for trigger point injections are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.