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 a bilateral MRI of the breast. ACRs updated guidelines suggest that, in the presence of a palpable mass, the next step should be biopsy or tissue sampling. ACRs algorithm for management of a patient with a palpable breast mass who is over 40 years of age indicates that the first imaging study should be a mammogram. If negative, a correlative ultrasound should be performed. If the ultrasound show suspicious features, a biopsy should be performed; if benign features are noted, either a biopsy or short-term follow up is appropriate. If the ultrasound is negative, the follow up is clinical evaluation by referring healthcare provider or surgeon. Of note, ACR does not include MRI as a component in its treatment algorithm. In this case, this 59-year-old patient had a palpable left breast mass in the 1:00 position noted twice on clinical examination that was mobile and 1 cm in size. A mammogram performed on 4/9/18 was negative. An ultrasound performed on 4/23/18 noted a suspicious area in left breast. A repeat ultrasound on 5/3/18 did not show this suspicious area, but progress notes from a 5/4/18 visit with the primary treater again noted a palpable mass. Per ACR guidance, the appropriate next step in this patients evaluation is biopsy or tissue sampling. Therefore, an MRI is not necessary for evaluation of this patients condition at this time.Final Result: The reviewer determined that the requested service is 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for IVIG (intravenous immune globulin) treatment with Octagam (HCPCS-J1568). Based on the current medical literature and the submitted documentation, there is a rationale and sufficient scientific data in the literature to support the use of high-dose IVIG for the treatment of this patients condition. There is sufficient outcome data available from case reports in published peer-reviewed literature that substantiates the safety and efficacy for the use of IVIG for post infectious autoimmune encephalitis. IVIG has shown benefit and is generally recognized by the medical community as effective and appropriate for this condition. This patients records document that prior treatment with IVIG resulted in a clinically meaningful response. Thus, the IVIG treatment with Octagam (HCPCS-J1568) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the IVIG treatment with Octagam (HCPCS-J1568) is 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 requested medication 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:  One reviewer is board certified in pediatrics and neurology with specialty qualification in child neurology and is actively practicing. One Reviewer is board certified in pediatrics with sub-specialty certification in pediatric infectious disease and is actively practicing.  One Reviewer is board certified in pediatrics with sub-specialty certification in pediatric infectious disease 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block therapy.Findings:  Three physician reviewers found that neuralgia is a type of neuropathic pain. Occipital neuralgia specifically refers to pain and/or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. This patient has been diagnosed with occipital neuralgia on examination. There are several options for management of occipital neuralgia, including antiepileptic drugs as well as tricyclic antidepressants, which the patient has not tried per the submitted documentation. The medical evidence has not established that occipital nerve block therapy was likely to have been more beneficial for the treatment of this patient than other available standard therapy. In sum, occipital nerve block therapy was not likely to have been superior over other available treatment options. 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/Qualifications: Physician reviewers 1, 2 and 3 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (Lineagen pharmacogenomic panel). Tantisira and colleagues noted that, Pharmacogenetic testing is available in some areas in conjunction with certain drug classes, and may enable physicians to understand why patients respond differently to various drugs and to make better decisions about therapy. However, the goal of individualized therapy based upon pharmacogenetic testing has yet to be realized. The pharmacogenomic testing is not the standard of care, and it has not been proven to be effective for the patients condition. Given these findings, the genetic testing (Lineagen pharmacogenomic panel) 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 genetic testing (Lineagen pharmacogenomic panel) 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 genetic testing (Lineagen pharmacogenomic panel) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 1 is board certified in genetics and clinical cytogenetics. Physician reviewer 2 is board certified in pediatrics, neurodevelopmental behavioral pediatrics, and genetics. Physician reviewer 3 is board certified in pediatrics, genetics, and clinical biochemical genetics. The Physician reviewers 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 reimbursement for genetic testing (CPT 81450).  Findings:  Two of the three physician reviewers found that chronic lymphocytic leukemia is characterized as an indolent leukemia, but a patients individual clinical course is not predictable. It is impacted by stage at presentation and certain biomarkers. Among these, mutations in TP53, NOTCH1, BIRC3, and SF3B1 have been shown to be helpful to categorize patients into prognostic groups. Thus, mutational analysis has been adopted by many oncologists at the time of chronic lymphocytic leukemia diagnosis. In addition to this indication, mutational analysis may also be needed in the case of treatment resistance. Many combinations of chemotherapies and newer agents have been shown to have a response in chronic lymphocytic leukemia, but none have clearly demonstrated an improvement in overall survival. Patients may exhibit resistance to therapy, and mutational analysis may be needed. This is particularly important for patients who have progressed on standard regimens. Alternatively, even U.S. Food and Drug Administration (FDA) approved therapies may require knowledge of patients mutations. For example, venetoclax is a BH3 mimetic drug that inhibits the function of the anti-apoptotic BCL2 protein. It is approved in chronic lymphocytic leukemia that has TP53 deletion. It targets a whole new class of cancer-causing proteins, but chronic lymphocytic leukemia mutational analysis is required for its proper use. Therefore, the current medical evidence supports the services at issue in this clinical setting. Thus, genetic testing (CPT 81450) was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a medication regimen of MS Contin and Norco. The Center for Disease Control (CDC) 2016 guidelines recommends that clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The CDC further recommends that patients should be counseled on the negative effects of opioids, and that tapering should be offered with average reductions of 10% each week. If negative effects including withdrawal are experienced by the patient, slower tapering could be considered including 5% per week or 10% per month. Lastly, the CDC recommends against reversing a taper, and instead suggests that the rate at which tapering occurs may be slowed or paused while monitoring and managing withdrawal symptomsIn this case, the submitted documentation supports that a High Risk Opioid Evaluation was performed. At that time, the significant adverse effects of opioids on the patients health were discussed. The patient was offered a tapering of the opioid dose from the maximum 420 morphine milligram equivalents (MMEs) per day to a lower dose. The patient consented to the recommended taper. Subsequently, the patient was started on a slow taper of ~5% per week with reductions in MMEs from 420 to 290 by end of June. The patient had an opioid use agreement in place since 2016 that included following the recommendations of the provider and regular urine toxicology screening. During the taper, the patient was administered the Screener and Opioid Assessment for Patients with Pain (SOAPP) instrument to assess risk of relapse/success. The patients SOAPP scores were recorded as less than 4, which is low risk. In conclusion, this patient has been tapered from high dose opioids according to established medical standards. The patient was apprised of the risks of maintaining a high dose opioid regimen, and thereafter consented to a taper. Current medical evidence recommends against reversing a taper for long-term opioid users. Therefore, reinstituting the higher 420 MME dose of opioids is not appropriate for this patient.Final Result: The reviewer determined that the requested medication regimen 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 anesthesiology, with subspecialty certifications in pain medicine, and hospice and palliative 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: Findings:  Two of the three physician reviewers found in this circumstance, there is potential for recovery of left ventricular function over time with medical therapy. Additionally, there was no documented indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest.  Placement of a prophylactic defibrillator is not recommended until a period of time greater than 90 days where continued left ventricular dysfunction is documented to persist despite appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. The medical records do not support the requested device in this clinical setting. In sum, the requested wearable cardioverter defibrillator rental is not likely to be more effective than other treatment options. Final Result: The reviewers determined the requested device 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 internal medicine with sub-specialty certification in cardiovascular disease 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: An enrollee has requested authorization and coverage for a computed tomography (CT) scan of the brain. In the continuing management of TBIs with intracranial hemorrhage, there are several modalities which can be employed. The primary modalities include CT and MRI. Obtaining imaging in the period post-TBI can play several important roles, including evaluation of underlying lesions, guiding rehabilitation and aiding in prognosis. MRI is considered a superior diagnostic imaging tool to CT brain imaging. It has been shown to better identify several abnormalities as compared with CT. In this case, the patient suffered a TBI. She had follow-up MRI which was reported as stable. Considering that MRI is generally accepted to be a more sensitive imaging modality, an additional CT scan would not be indicated at this time.Final Result: The reviewer determined that a CT scan of the brain is not medically necessary for evaluation of the enrollees medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  The physician 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic esophageal sphincter augmentation procedure with placement of a sphincter device (CPT code 43284). Findings:  Two of the three physician reviewers found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not demonstrate that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. Thus, laparoscopic esophageal sphincter augmentation procedure with placement of a sphincter device (CPT code 43284) is not likely to be more effective than other available treatment options. Final Result: The reviewers determined that the requested services are 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon ostial dilation. According to the American Academy of Otolarygology, sinus ostial dilation is a therapeutic option for selected patients with chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis (RARS) who have failed appropriate medical therapy. Clinical diagnosis of CRS and RARS should be based on symptoms of sinusitis and supported by nasal endoscopy documenting sinonasal abnormality or mucosal thickening on computed tomography of the paranasal sinuses. Chronic rhinosinusitis was not documented in this patient as there was no documentation of 12 weeks of consecutive disease. In addition, recurrent acute sinusitis was not documented in this patient as there was no documentation of four or more recurrent episodes over a one year period. Overall, there was no documentation of chronology of disease, symptoms or treatment. Moreover, the CT from 2015 was unremarkable with minimal sinus disease. Endoscopic examination revealed resolution of mucopurulence after antibiotic therapy. For these reasons, balloon ostial dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found balloon ostial dilation 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 balloon ostial dilation 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 otolaryngology 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: The parent of an enrollee has requested reimbursement for the GeneSight Drug-Gene testing. Pharmacogenetically-guided dosing is supported in the medical litearture for use in pediatric oncology and gastroenterology as well as to guide clinical decision making for psychotropic medications based on the Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. In the clinical reviews, there is limited data demonstrating improved patient health outcomes when treatment is directed by genetic testing. In a recent review article, the authors determined that there were not enough genetic, pharmacogenetic and biochemical studies of ADHD in adults andmore investigations are needed. Ultimately, more research is needed to understand the contributions of pharmacogenomics testing in the clinical treatment of children and adolescents. Given these findings, the GeneSight Drug-Gene 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 GeneSight Drug-Gene testing that 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 GeneSight Drug-Gene testing that was was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics, neurodevelopmental behavioral pediatrics, and genetics and is actively practicing. Physician reviewer 2 is board certified in genetics and clinical cytogenetics and is actively practicing. Physician reviewer 3 is board certified in pediatrics and genetics 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.