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

Nature of Statutory Criteria/Case Summary: A 61-year-old female enrollee has requested authorization and coverage for the Inspire neurostimulation upper airway implant procedure. Findings: The physician reviewer found that Obstructive sleep apnea (OSA) is clinical problem with significant effects on a patients health. Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy and low morbidity with long-term adherence rates approaching 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. There is adequate clinical data demonstrating that the hypoglossal nerve stimulator is safe and effective in a small subset of patients with OSA who have failed CPAP. The patients BMI, AHI and nonconcentric airway collapse, meets the criteria for hypoglossal nerve stimulation. Moreover, she has failed CPAP which is the gold standard treatment for OSA. For these reasons, the requested Inspire neurostimulation upper airway implant procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer found that there is insufficient evidence from randomized controlled trials or comparative effectiveness trials with long-term follow-up, comparing hypoglossal nerve stimulation to established procedures for the treatment of obstructive sleep apnea. Final Result: Two of the three reviewers determined that the requested procedure is 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 otolaryngology and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement and prospective authorization and coverage for edaravone. Findings: The physician reviewer found that Radicava is U.S. Food and Drug Administration (FDA) approved for patient with ALS. Although the evidence for the benefit of Radicava has been shown in patients with early ALS, as defined in the pivotal trial, there is a lack of rationale demonstrating that the population evaluated in that trial is biologically distinct from the greater ALS population. Moreover, the FDA approved Radicava for ALS patients without any restriction. Therefore, treatment with Radicava is clinically indicated for this patient. All told, edaravone (Radicava) provided was and is 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 medication at issue was and 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 neurology and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for retinoblastoma susceptibility gene (RB1) genetic testing. The Health Plan has denied this request indicating that the requested testing is not medically necessary for evaluation of the enrollees family history of retinoblastoma. Full testing of the RB1 gene is not clinically indicated for this patient. However, testing specifically for the mutation previously identified in her family members is medically necessary to determine if she has inherited the same mutation, if she is at risk for RB1-related cancers, and if she has risk of having affected children. In this case, the patient has a known family history of retinoblastoma. The specific mutation of p.R661W is known to have reduced penetrance, which means that not all those who inherited this mutation will develop retinoblastoma or other RB1-related cancers. There has been an identified parent-of-origin effect with this mutation. Though exact reasons remain unclear, this is likely due to imprinting effects. Therefore, testing for the family mutation would provide useful information for both medical management and reproductive planning for this patient. As such, single-site testing for the RB1 mutation identified in her family members has been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested testing is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in clinical biochemical genetics 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 gene panel testing. Findings:  Three physician reviewers found there is sufficient support for a portion of the services at issue. The American College of Obstetricians and Gynecologists recommends that providers offer screening for spinal muscular atrophy to all patients who are considering pregnancy or who are currently pregnant. The records document that this patient underwent screening for spinal muscular atrophy. Thus, the medical evidence supports this testing in this clinical setting. However, the submitted documentation indicates that CPT code 81401 is in dispute. This code represents a complete gene panel. The records did not provide further support for the remaining of the tests which were included in the gene panel testing. In sum, screening for spinal muscular atrophy was likely to have been of greater benefit than other methods of evaluating this patient. However, the superior efficacy of the remaining tests of the gene panel testing has not been established.Final Result: The reviewers determined that a portion of the services 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 partially overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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: A female enrollee has requested authorization and coverage for the placement of a LINX augmentation device esophagus. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).The LINX System has not been studied in patients with Barretts esophagus. Although this patient has a confirmed diagnosis of GERD, Bravo pH testing revealed poor symptom correlation with acid reflux. In addition, implantation of LINX in this clinical setting must be approached with caution given her underlying Barretts esophagus. As such, the placement of a LINX augmentation device esophagus 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 procedure is 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ambulance transportation services provided. The Health Plan has denied this request indicating the services at issue were not necessary for treatment of an emergency medical condition.The ambulance transportation services provided were not necessary for treatment of an emergency medical condition. The patient was experiencing abdominal pain. The patient also had been experiencing small amounts of intermittent blood in his stool. The patient had a history of similar symptoms a year ago and suffered from constipation. There was no vomiting or diarrhea. The patient had normal vital signs and was in no distress. The patients airway was patent and lungs were clear. The onset of abdominal pain without other symptoms does not meet criteria for emergency medical services.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a lumbar epidural steroid injection. A peer-reviewed medical literature noted that epidural steroid injection has shown short-term improvement for patients with radicular pain but not for other types of low back pain. The current standard of care supports epidural steroid injection for patients with object examination findings of radiculopathy due to herniated nucleus pulposus, but not spinal stenosis.  In addition, radiculopathy must be corroborated by imaging studies and/or electrodiagnostic testing, and the condition must be initially unresponsive to conservative treatment including exercises, physical methods, non-steroidal anti-inflammatory drugs (NSAIDs) as well as muscle relaxants. This patients medical records do not document physical examination and imaging study findings consistent with radiculopathy to support the request for epidural steroid injection. Given these findings, the requested lumbar epidural steroid injection is not medically necessary. Final Result: The reviewer determined that the requested service 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 pain 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 gene panel test (FoundationOne) for treatment of the enrollees prostate cancer. Findings:  The physician reviewer found that Although tumor based molecular assays are recommended by the National Comprehensive Cancer Network (NCCN) guidelines for men with clinically localized disease, generalized molecular testing such as FoundationOne is not supported by the NCCN guidelines for prostate cancer. The use of molecular profiling for prostate cancer and other solid tumors is the subject of ongoing clinical trials. The available literature indicates that the use of molecularly targeted agents, outside their indications, do not improve progression free survival compared with treatment recommended by a provider in heavily pretreated patients with cancer. There is also some data suggesting that intratumoral heterogeneity limits the use of gene expression analysis as a potential prognostic or predictive biomarker in patients treated with androgen deprivation therapy. As such, the use of FoundationOne testing is not likely to be more beneficial than any available standard therapy. Therefore, the gene panel test (FoundationOne) provided was not likely to have been more effective than the standard methods available for evaluating this patients medical condition. Final Result: All three reviewers determined 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gallbladder removal surgery. Findings: The physician reviewer found that the submitted documentation supports the requested services in this patients case. Cholecystectomy can be effective for management of biliary colic associated with gallbladder disease, regardless of the presence of gallstones. It can resolve biliary colic, even when the gallbladder ejection fraction is normal on hepatobiliary scan. In this case, the patient has symptoms consistent with biliary colic or gallbladder-associated pain, and there is a good possibility that cholecystectomy may result in resolution of her abdominal pain. All told, the requested gallbladder removal surgery 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: An enrollee has requested reimbursement for mandibular adjustment device. The Health Plan has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees obstructive sleep apnea (OSA).The documentation provided does not support the medical necessity of the device at issue in this clinical setting. In this case, the patient was prescribed an oral appliance. It cannot be determined from the medical records provided, if the patients first sleep study was diagnostic for OSA as the total AHI was not provided. Additionally, current practice state that although oral appliances (OAs) have been shown to improve physiologic sleep parameters, CPAP (continuous positive airway pressure) appears, in our meta-analyses, to be superior to OAs in reducing the AHI, arousal index, and oxygen desaturation index and improving oxygen saturation, and therefore should still generally be the first-line option for treating OSA. Likewise, guidelines from the American College of Physicians also recommend the use of CPAP as a first-line therapy for OSA. Based on the documentation provided for review, the mandibular adjustment device was not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the device at issue was 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 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 a four corner fusion surgery with compression FT screws for treatment of the enrollee who has a history of left wrist pain. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case. A study indicated that four corner fusion had been shown to be a reliable option of treatment of wrist arthritis. They concluded that four corner fusion using headless retrograde headless screws demonstrated a low complication rate and high fusion rate, and could therefore be considered a reliable surgical technique. Another study concluded that four corner fusion, including with headless compressive screws, is a reliable wrist fusion technique that provides pain relief, grip strength and satisfactory range of motion in patients with degenerative conditions of the wrist. Partial union is more common with Kirschner wire fixation and complications are more common with circular plate fixation. The researchers concluded that four corner arthrodesis using headless compression screws was comparable to or better than the results of previously published techniques. This technique exploits the theoretical advantages of strong compression between carpals while avoiding a screw head sized hole in the lunate articular cartilage and preserving the dorsal capsular ligament attachments to the triquetrum. This patient presented with constant intense left wrist pain for over one year with markedly limited range of motion. The patient had been diagnosed with a non-union fracture and left wrist end stage (bone on bone) osteoarthritis. The patient failed to improve despite over the counter anti-inflammatories, activity modification, physical therapy, and prior PIN. Current evidence based peer reviewed literature support the use of four corner fusion with headless compression screws with comparable or better results in terms of fusion rate, pain relief, grip strength, and satisfactory range of motion. Therefore, a four corner fusion surgery with compression FT screws is 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for whole exome sequencing. The Health Plan has denied this request indicating that the requested services are considered investigational for evaluation of the enrollee who has a history of mycoplasma pneumonia.  Findings: There is sufficient support in the medical literature for the efficacy of WES in this clinical setting. Based on the patients documentation, he would be a good candidate for WES, given his multi-system disease, with progressive pulmonary disease, immune system abnormalities, complement abnormalities, joint pain, and abdominal symptoms.  These multisystem findings increase the likelihood of an underlying single gene disorder, which can be identified by WES. Researchers identified causative diagnosis in 25 percent of 250 probands studied with WES. This yield is higher than genetic technologies previously considered standard, such as karyotype analysis or chromosomal microarray. A study found similar detection rates. For these reasons stated above, WES is likely to be more effective than the available standard modalities for the evaluation of this patients medical condition.Final Result: Three reviewers determined that whole exome sequencing is likely to be more beneficial than the available standard therapy for evaluation of patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in pediatrics and genetics 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.