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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacroiliac radiofrequency ablation for treatment of the enrollees chronic low back pain.  Findings:  The physician reviewer found that this patient is being treated for low back pain. Imaging does not support the presence of inflammatory sacroiliitis and she does not have a history of extensive spinal surgery for which a SI joint fusion might be considered. In this case, the patient underwent a SI joint injection with medications including fentanyl. Use of intravenous sedation may be grounds to mitigate the results of a diagnostic block. Radiofrequency facet joint denervation of spinal nerves in the treatment of SI joint pain is not supported in this clinical setting. The safety and effectiveness of this procedure has not been established by review of the available published peer-reviewed literature. Larger, well-designed trials are needed for comparing specific procedures in defined populations for use in SI pain and to determine the potential candidates and treatment parameters for this disorder. Additionally, this patient had partial relief when receiving chiropractic treatments. Conservative care is the current recommendation for her condition. Thus, the requested SI radiofrequency ablation is not likely to be more beneficial for treatment of her medical condition than available standard therapy.Final Result: All Three reviewers determined that the requested SI radiofrequency ablation is not likely to be more beneficial for treatment of her medical condition than available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for chiropractic manipulation. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients back pain. The submitted documentation supports the medical necessity of the requested services. The patient has a history of chronic low back pain and has trialed nonsteroidal anti-inflammatory drugs, which resulted in gastrointestinal side effects. The patient has also received physical therapy. Research studies show moderate efficacy of spinal manipulation for chronic or subacute low back pain. There is sufficient support for the requested services in this clinical setting. Thus, the requested chiropractic manipulation 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 chiropractic 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 Stelara every four weeks. The medical literature supports dose escalation of Stelara in this patients case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease. A significant majority of these patients were able to discontinue steroids. In this case, alternative therapies are limited, as the patient has failed other biologic therapy for Crohns disease. For these reasons, Stelara every four weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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 patient has requested reimbursement for psychiatric residential treatment center level of care for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that The submitted documentation does not support the medical necessity of the services at issue. The patient was admitted due to oppositional behavior at home, failing at school, anxiety, and treatment for ADHD. During the dates of service in dispute, the patient did not have suicidal thoughts. The patient had no substance abuse history. Overall, this patient interacted well with staff and peers. The patient was engaged and participated in treatment. The patient had no history of aggression and did not exhibit aggressive behavior towards others. The patient was compliant with medication therapy. The patient continued to have some OCD symptoms with some increased anxiety, but was described as having an otherwise stable mood. The record indicates that this patient had improved enough to be discharged to a less restrictive environment. The patient did not have symptoms that require 24-hour supervision. The patient continued to require treatment for ADHD, OCD, and generalized anxiety disorder. However, the patient could have been treated in a less restrictive environment. Therefore, psychiatric residential treatment center level of care provided  were not medically necessary for the treatment this patient.Final Result: The reviewer determined that the services at issue were 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 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: A 47-year-old female enrollee has requested authorization and coverage for a 30 day residential treatment center services. The records provided for review do not support the medical necessity of 30 day RTC services for treatment of this patients medical condition. The patient is not a danger to herself or others and she is not in withdrawals or at imminent risk. She was placed on an outpatient detoxification protocol with Topamax and Librium. There have been no emotional, behavioral, or cognitive factors which suggest the need for substance abuse RTC level of care. She is medically and psychiatrically stable. She is not manic or psychotic, and she has not shown any highly impulsive or risk-taking behavior requiring the restrictive setting of RTC. Her detoxification protocol does not require an inpatient setting. She previously did well in a day treatment program and was able to maintain sobriety. There is no evidence to show that her home environment is unstable, unsafe, or not supportive. She can be safely treated at an ambulatory level of care with the additional support of community services in the 12 step groups with Alcoholics Anonymous. Thus, the requested 30 day RTC services are not medically necessary. 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 psychiatry with sub-specialty certification in addiction 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency neurolysis. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees back pain. Findings:  In the documentation available for review, the provider does not document an examination consistent with facet arthropathy prior to the requested procedure. The literature recommends that a diagnostic medial branch block is to be performed prior to radiofrequency ablation, specifically using a pain diary for the day to verify when the local anesthetic wore off and not using anything other than a local anesthetic for the test. The records indicate that at least two years later, the procedures were repeated. However, the medical records during the time of the prior ablation and the prior medial branch blocks, the corresponding pain dairies were not submitted to corroborate any improvement. There was no mention of a baseline functional status with an actual number value and no perceived pain baseline with an actual number value. In addition, these procedures are not recommended when a patient has radicular problems. The literature indicates that a steroid injection alone may provide relief without having the increased risk from a radiofrequency ablation procedure. From the submitted records, there is no mention of prior failure from facet injections or epidural injections. Finally, there is no mention of a home exercise program. These treatment modalities are standard of care and may have provided benefits to this patient with less risk. Therefore, the records provided have not demonstrated that radiofrequency neurolysis was a superior treatment modality when compared to standard methods of treating this patients medical condition.  Final Result: All three reviewers have 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/Qualifications:  All three reviewers are board certified anesthesiology with sub-specialty certification in pain medicine and are actively practicing. All three 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: The enrollee has requested reimbursement for the hormone implants (CPT codes 11980 and J3490). Low testosterone can lead to such complications as reduced libido and erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis, depressed mood, and fatigue (Dandona and Rosenberg). For these reasons, current data supports treatment of patients with hypogonadism when their testosterone level is less than 350 ng/dL (Nieschlag, et al). While topical gels and intramuscular injections are the most commonly prescribed formulations for testosterone replacement therapy, the short half-life of testosterone may be problematic for some patients. These modalities can often lead to highly variable levels of testosterone, resulting in poor patient compliance. Implantable testosterone pellets are an alternative therapy which provides a long-lasting effect (McCullough). For this reason, testosterone pellets may be of benefit to certain patients, such as this patient, who cannot achieve optimal clinical or biochemical results from the transdermal or intramuscular testosterone replacement therapy. Given these findings, the hormone implants (CPT codes 11980 and J3490) provided were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the hormone implants (CPT codes 11980 and J3490) provided were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing.  All three 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: A 26-year-old male enrollee has requested reimbursement for the residential treatment center  services. The patient did not report post-acute withdrawal symptoms. He was not a danger to himself or others, nor was he aggressive or violent. He was cognitively intact and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was medically and psychiatrically stable. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was motivated and appeared to be working the program. He was cooperative and participating in his treatment plan. Although he continued to struggle with his emotions and required further treatment to help develop coping skills, this did not require the structured residential setting with 24-hour nursing and medical monitoring. Based on the available documentation, the patient could have been safely and adequately treated at a less restrictive level of care. All told, the RTC services provided  were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issuer were 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 psychiatry with sub-specialty certification in addiction 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for 24-hour a day shift nursing care. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patient, who has a history of anoxic encephalopathy. The submitted documentation supports the medical necessity of a portion of the requested services. Based upon the records and medical literature, 60 hours per week is recommended in this clinical setting, to be utilized flexibly to allow the parental caregivers to work. The patient has skilled medical needs that include administration of oxygen via tracheostomy collar, tracheostomy suctioning, tracheostomy changes, gastrostomy tube feeding, and medication administration via gastrostomy tube. When the parents are not available due to working outside of the home, a skilled care provider is required to meet the care needs of this patient. The medical evidence supports a portion of the requested services. All told, 60 hours per week of shift nursing care is medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services are 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical traction equipment (CPT E0855). Findings:  Two of the three physician reviewers found cervical traction, which involves the manual or mechanical distraction of vertebral bodies and facet joints to reduce pain from nerve irritation, is frequently prescribed in the setting of neck pain, cervical radiculitis and cervical radiculopathy. However, the quality of evidence in support of this practice is not strong. The evidence supporting this practice is largely anecdotal in nature. This treatment has not been shown objectively in rigorously designed studies to improve health or functional outcomes.  It is not proven to be an effective adjunct or substitute for standard conservative care, including exercise, stretching, topical thermal modalities, rest and analgesics. Therefore, the requested cervical traction equipment (CPT E0855) is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested equipment 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 physical medicine and rehabilitation 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: A 43-year-old female enrollee has requested reimbursement for the genetic testing, BRCA1 and BRCA2 (CPT code 81211). This patients family history is suggestive of a breast/ovarian cancer syndrome. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. The MyRisk panel was indicated for further assessment of this patients cancer risk since the current clinical situation may be caused by several potential cancer causing genes. All told, the MyRisk genetic panel testing (CPT 81406 and CPT 8147959), excluding the covered BRCA 1 and BRCA 2 testing, provided on 2/22/18 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the MyRisk genetic panel testing (CPT 81406 and CPT 8147959), excluding the covered BRCA 1 and BRCA 2 testing, provided on 2/22/18 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three 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: A patient has requested authorization and coverage for doxycycline IR-DR (Oracea). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients rosacea. The submitted documentation does not support the medical necessity of the requested medication. Per the documentation, a trial of doxycycline IR-DR (Oracea), with some improvement. The record did not indicate that the patient has not tried one topical sulfacetamide-sulfur product and one topical metronidazole product. The medical records indicate that the patient was prescribed Oracea in 2016 and then again in 2018. The medical records do not support the necessity of Oracea over the generic topical agents or generic doxycycline. The records fail to demonstrate a lack of efficacy or intolerance to the preferred agents. Therefore, doxycycline IR-DR (Oracea) is not medically necessary for the treatment of this patient.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 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.