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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for functional electrical stimulation NOS. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees relapsing remitting multiple sclerosis. Findings:  According to current published evidence within peer reviewer literature, it is insufficient to conclude that functional electrical stimulation (FES) will improve health outcomes in patients with multiple sclerosis. The studies published to date have had significant methodological drawbacks and were case series rather than well power-randomized trials and have also failed to present conclusive evidence regarding whether FES improves treatment outcomes in patients with MS, particularly when compared to other treatment modalities. The current literature is also limited and demonstrates an incomplete assessment of net benefit versus harm and additional research is necessary to permit conclusions on the benefit of the requested device or technology in aiding ambulation in patients with MS. Therefore, the functional electrical stimulation NOS was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/QualificationsAll three reviewers are board certified in neurology 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 parent of an enrollee has requested authorization and coverage for intravenous immune globulin (IVIG) therapy. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient was diagnosed with anxiety and depression and non-epileptic convulsions during a hospital stay. He was prescribed pharmacotherapy for anxiety and depression along with outpatient psychiatric treatment. He had a normal MRI of the brain that was not consistent with encephalitis, and his EEG showed no evidence of epileptiform activity. A diagnosis of autoimmune encephalitis was made by a treating provider, but it is not clear on the basis of what criteria this diagnosis was made. The records do not document abnormal autoimmune markers. Furthermore, his brain imaging, EEG and physical examination were not suggestive of encephalitis. While it was reported that the patient received IVIG and experienced temporary improvement in abnormal movements, it was not clear that this was as a direct result of the IVIG nor was it a sustained effect. IVIG is not a benign therapy and has potentially significant side effects, including anaphylaxis, renal failure, fever, headache, muscle cramps, and pain. The medical evidence does not support the requested services in this clinical setting. Therefore, IVIG is not medically necessary for the 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 pediatrics with sub-specialty certification in pediatric 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: An enrollee has requested reimbursement for continuous positive airway pressure (CPAP) supplies. The submitted documentation supports the medical necessity of the requested equipment. This patient was diagnosed with obstructive sleep apnea and was prescribed CPAP therapy. It is well-established within current practice guidelines that CPAP supplies should be replenished on a periodic basis for patients who are compliant with treatment. This is in part to maximize patient therapy with the devices. In this case, the replacement supplies that were furnished to the patient were medically indicated. Therefore, CPAP supplies were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the equipment at issue was 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 sub-specialty certification in sleep 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 Elestrin gel. According to the American College of Obstetricians and Gynecologists (ACOG), systemic hormone therapy, with estrogen alone or in combination with progestin, is most effective for vasomotor symptoms. For vulvovaginal atrophy leading to sexual dysfunction, topical estrogen formulations are the most effective. Current data suggests that tablets, gels, creams, and vaginal rings are equally effective. The records indicate that this patient is status post surgical menopause. She was treated with systemic oral estrogen for her menopausal symptoms, which was changed to a transdermal route. The patient cannot tolerate treatment with patches, but experienced good results with Elestrin gel. All told, the requested Elestrin gel is supported as medically necessary for treatment of this patients vaginal atrophy. 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 obstetrics and gynecology 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 parent of an enrollee has requested authorization and coverage for Cymbalta, gene testing for medication (Genesight test), and cognitive therapy twice a week for treatment of the enrollees medical condition. Regarding the requested gene testing for medication (Genesight test), the evidence base does not appear to support the use of pharmacogenomic testing under the present circumstances. Studies by researchers point out that there is still considerable controversy on whether the adjustment of dosage driven by genetic information may improve therapeutic efficacy, and/or whether adverse events are prevented, to an extent of any practical importance in clinical practice. These references also mention that routine application of pharmacogenetic dose adjustment in clinical practice requires prospective validation. Therefore, the requested gene testing for medication (Genesight test) is not medically necessary.Regarding the request for the antidepressant medication Cymbalta, this medication is not approved by the FDA for patients of this age. This medication is not medically necessary as it has not been studied to be effective or safe in this patients age range.Regarding the request for cognitive therapy on a twice weekly basis, the records show that the patient has numerous problematic behaviors and aggression and that she has been tried on several medications in the past. It appears that she has undergone group and individual therapy. Twice weekly therapy is medically necessary and indicated for the patient due to her overall functional level.Final Result: The reviewer determined that a portion of the medication and services at issue are medically necessary for treatment of the patients medical condition. Specifically, the reviewer has determined that the requested cognitive therapy twice a week is medically necessary. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry, with a sub-specialty in child and adolescent 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dexcom continuous glucose monitor. A continuous glucose monitoring system records blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed. The device can help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar and evaluate how diet and exercise affect blood sugars. It can be used as a precautionary device in order to prevent potentially dangerous consequences of uncontrolled diabetes. Continuous glucose monitoring systems have been shown to improve hemoglobin A1C levels of diabetic patients. The medical evidence supports the requested device in this clinical setting. Therefore, Dexcom continuous glucose monitor 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 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: An enrollee has requested authorization and coverage for Gel One injections in the right knee. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis. In addition, the benefits of intraarticular hyaluronic acid injections are long-lasting when compared with intraarticular corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a suitable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Gel One injections in the right knee are supported as medically necessary for treatment of this patients medical condition. 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 vagus nerve stimulation (VNS) therapy. When a patient with partial seizures fails two drug medical treatment, and does not have an epileptic focus that can be resected surgically, VNS may be an appropriate option for therapy. Researchers concluded that VNS is an effective and safe method to refractory epilepsy in common clinical practice. VNS has been demonstrated to be safe and effective in this clinical setting in a large number of patients who were medically refractory and not amenable to surgery. Given this support, the requested VNS therapy is medically necessary for treatment of this patients medically refractory partial seizures. 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for consultation with a pain management provider. The medical documentation does not support the medical necessity of the requested services. Per the American Academy of Pain Medicines guidance, referral to a pain management specialist is appropriate when current treatment is not helping. In this case, the patient recently underwent two drug screens, both of which suggest that the patient is not taking Norco as prescribed (if at all). The patient has also very recently been prescribed gabapentin and has not yet completed the prescribed course of physical therapy. Since no evidence has been presented showing that the current treatments cannot help manage/cure the patients pain, referral to a pain management specialist is not appropriate at this time.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 anesthesiology 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 Repatha Sureclick pen injector. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria. In this setting, several prospective randomized trial have demonstrated safety, significant reduction in LDL cholesterol and outcomes improvement with the addition of PCSK9 inhibitors. Therefore, Repatha Sureclick pen injector 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 cardiovascular disease 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 nasal scar revision. There is sufficient support for the requested services in this clinical setting. Photographs support the clinical documentation of significant scarring of the nose. However, no functional impairment has been associated with the external scar. Therefore, scar revision is not medically necessary at this point based on a functional consideration. However, the patients condition constitutes an abnormal structure of the body. Scarring an abnormal condition of the body. This abnormal structure is caused by acne, which is a disease. There is no evidence of functional impairment, but the procedure would be performed to help create a more normal appearance. Based on the records, the requested surgery would offer more than a minimal improvement in the appearance of the enrollee. Therefore, the requested nasal scar revision is reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition but are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Gene Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Gene Assay testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Gene Assay testing 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 DecisionDx-Melanoma Gene Assay testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the laparoscopic anti-reflux surgery (LINX procedure). Overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication. Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Therefore, the requested laparoscopic anti-reflux surgery (LINX procedure) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested laparoscopic anti-reflux surgery (LINX procedure) 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 laparoscopic anti-reflux surgery (LINX procedure) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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.