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

Nature of Statutory Criteria/Case Summary:    An enrollee has requested the LINX Anti-Reflux procedure for treatment of her medical condition.   Three physician reviewers found that it is not clear that this patient has symptoms related to acid reflux.  This is based on her normal DeMeester score and poor response to acid secretory inhibitory therapy.  The LINX device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter closure pressure, but allow for food passage with swallowing.  The results from early studies at four years are encouraging.  However, controlled data for the procedure are lacking.  The current medical evidence has not demonstrated that the device is more efficacious than fundoplication and whether it has the durability of fundoplication.  All told, the superior efficacy of the LINX Anti-Reflux procedure has not been established.   Final Result: Three 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 bilateral knee magnetic resonance imaging (MRI) without contrast, MRI of the thoracic spine without contrast, and MRI of the lumbar spine without contrast for evaluation of her back pain and bilateral knee pain.  The physician reviewer found that this patient has chronic bilateral knee pain limiting physical activity and has had courses of conservative therapy including physical therapy in the past. Plain films show bilateral degenerative changes. Since conservative management has failed to relieve her knee pain the next logical choice in evaluation is MRI. While there are degenerative changes seen on plain film x-rays, and these changes potentially could explain her knee pain. Thus, MRI evaluation is indicated to look for other causes of internal derangement including meniscal disruption, ligamentous abnormality, and loose bodies. In addition, the MRI of the lumbar spine is medically necessary since the patient has bilateral radicular pain and importantly has undergone a course of physical therapy with no improvement. There is also a prior MRI of the lumbar spine showing a herniated disc at L4-5. Due to the radicular symptoms, failure of physical therapy and a known prior positive MRI finding, a repeat MRI of the lumbar spine is reasonable. However, the requested MRI of the thoracic spine is not medically necessary as the patient has no history of trauma and no thoracic spine symptoms by dermatome. Coupled with a negative plain film series of the thoracic spine, the requested MRI of the thoracic spine is not medically necessary. Accordingly, the requested bilateral knee and lumbar MRI scans are medically necessary per National Imaging Associates (NIA) clinical guidelines while the requested MRI of the thoracic spine is not medically necessary per NIA guidelines.  Final Result: The reviewer determined that a portion of the requested diagnostic procedures are 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the LINX Reflux Management System for treatment of his gastroesophageal reflux disease (GERD). Two physician reviewers found that currently, there is a paucity of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. An 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. In addition, another best-evidence review concluded that further studies are required to determine its long-term outcomes and its relative efficacy as compared to other established treatments. Adverse events, such as erosion through the esophagus, have also been reported in the period after U.S. Food and Drug Administration (FDA) approval. Given these findings, the requested LINX Reflux Management System is not likely to be more beneficial for treatment of your medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested procedure 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gene tests (CPT 81225, 81226, 81227, 81355, and 81401 for evaluation of his hypertension.   Three physician reviewers found that based on the records provided, the patient presented to his provider with some coronary risk given his diagnosis of hypertension but no documented symptoms or objective findings to suggest active coronary disease. In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations including the Expert Panel on Detection, Evaluation, and Treatment of High Blood Pressure in Adults. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phosholipase A2 (Lp-PLA2), sub-classifications of LDL, HDL subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, homocysteine, Factor V Leiden mutation, Factor II mutation and other genetic testing for mutations that increase the risk for thrombosis and cardiovascular disease. In addition, treatment changes based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Thus, the gene tests (CPT 81225, 81226, 81227, 81355, and 81401) were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-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 laparoscopic paraesophageal hernia repair and gastrointestinal endoscopy for treatment of his obesity and hiatal hernia. The physician reviewer found that this patient is morbidly obese and meets all standard nationally accepted criteria for bariatric surgery and was approved for laparoscopic Roux-en-Y gastric bypass. In addition, the patient was found to have a hiatal hernia on endoscopy. The provider has recommended surgical repair. While there is no CPT code for laparoscopic hiatal hernia, the most appropriate CPT code for use is 43281, which is laparoscopic paraesophageal hernia repair without mesh. A concomitant hiatal hernia identified pre-operatively or intraoperatively of moderate size should be repaired regardless of the presence of symptoms to prevent secondary complications of worsening or new onset gastroesophageal reflux, increasing hiatal hernia and herniation of the gastric pouch. The laparoscopic concomitant repair of the hiatal hernia is considered medically necessary as a secondary procedure with modifier 51. However, the use of an endoscopy for leak test and evaluation of bleeding is not considered a necessary component of the procedure. Moreover, the current medical literature does not support the need to utilize endoscopy to perform laparoscopic Roux-en-Y gastric bypass. The endoscopy is not considered a separate or secondary billable procedure but part of the method the provider uses to perform laparoscopic Roux-en-Y gastric bypass. Consistent with these findings, the requested laparoscopic paraesophageal hernia repair is medically necessary for treatment of this patients medical condition, but the gastrointestinal endoscopy is not medically necessary for treatment of this patients medical condition. 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 general surgery with sub-specialty certification in minimally invasive and bariatric 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:   The parent of an enrollee has requested two hours per week of in-home applied behavioral analysis (ABA) therapy for treatment of the enrollees behavioral health condition.  Three physician reviewers found that the submitted documentation fails to establish the medical necessity of the requested services. Based upon the documentation provided, the patient has been evaluated thoroughly by the school district and by a psychologist. Both evaluations note that the patient does not have any autistic traits. The evaluations conclude the patient has ADHD, borderline intellectual function and disruptive mood dysregulation disorder. Both evaluations provided extensive treatment recommendations. Furthermore, there is a lack of evidence in the literature to support use of ABA as a treatment modality for a patient who is not diagnosed with autism spectrum disorder.  Final Result:  Three reviewers 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: One reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing.  Two reviewers are board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry 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 Harvoni for 12 weeks for treatment of her chronic hepatitis C virus genotype 4.  Findings:  Three physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 4 infection in treatment naive patients. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. FDA approved antiviral therapy regardless of fibrosis score. All told, the medical literature supports the requested Harvoni for 12 weeks as medically necessary for treatment of this patients hepatitis C viral infection. Final Result: Three reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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:   The parent of an enrollee has requested magnetic resonance imaging (MRI) of the brain with and without contrast and MRI of the sella turcica with and without contrast for evaluation of the enrollees structural abnormalities possibly related to hypotonia and developmental delay.  The physician reviewer found that this patient presents with well documented developmental delays which supports the medical necessity for MRI imaging. Additionally, his specific neurological examination of hypotonia and delayed development suggests that the patients cerebellum may be abnormal. To determine the structural integrity of the cerebellum is by MRI imaging. This patient also has multiple minor facial anomalies which would significantly increase the possibility of an abnormal cerebral MRI. The standard of care for assessing a child with unexplained developmental delay includes a careful developmental assessment, a complete neurological examination, a comparative genetic microarray and a cerebral MRI.  However, the MRI views of the sella turcica are not medically necessary. Typically, in the clinical setting of an elevated TSH and a normal T4, the common anomaly is an aberrant thyroid, and a thyroid scan would be indicated.  For the reasons provided, the MRI of the brain with and without contrast is medically necessary. However, the request for an MRI of the sella turcica is not clinically indicated.   Final Result: The reviewer determined that a portion of the requested services are 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 pediatrics and child neurology with sub-specialty certification in neurodevelopmental disabilities 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 open nasal reconstruction surgery for treatment of his nasal obstruction.  The physician reviewer found that the request for open nasal reconstruction surgery is medically necessary for treatment of the patients medical condition. In this case, the patient presents with a post-traumatic septal/nasal deformity producing a crooked nose and airway obstruction. A crooked nose typically produces an abnormal nasal airway and nasal airway obstruction. Open nasal reconstruction surgery is medically necessary to correct the patients deviated dorsum and airway obstruction. Given that the spreader graft was placed on the right side, and not the left side the patients nose is likely still deviated. For the reasons provided the request for open nasal reconstruction surgery is medically necessary in this clinical setting.  Final Result: The reviewer determined that the requested surgery 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 otolaryngology and plastic and reconstructive surgery with sub-specialty certification in facial 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient hospitalization services for treatment of the enrollees medical condition.  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient was admitted for continued pain after surgical treatment of a bowel obstruction.  She had an exploratory laparotomy with lysis of adhesions and repair of small bowel serosal tears.  The patient was managed with total parenteral nutrition, a pain pump, and a heparin drip.  Subsequently, the patient was tolerating a full liquid diet, oral pain medications and was changed to Lovenox from heparin.  It was medically reasonable to continue the hospitalization until the patient was controlled with oral pain medication, a full liquid diet and Lovenox for her embolism.  All told, inpatient hospitalization services were medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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 a 12 week course of Harvoni for treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that Harvoni is medically necessary and the standard of care for the treatment of the patients with hepatitis C, genotype 1. In addition, treatment with Harvoni is expected to be beneficial by potentially curing hepatitis C infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. Moreover, per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America treatment guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration approved antiviral therapy regardless of fibrosis score. Thus, Harvoni for 12 weeks is medically necessary for treatment of the patients medical condition. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Harvoni for eight weeks for treatment of her hepatitis C virus (HCV).  Findings:  Three physician reviewers found that based on the documentation submitted for review, it is likely that this patient has advanced fibrosis. In addition, the patient is treatment naive with a low viral load and therefore eight weeks would be the appropriate duration. Final Result: Three reviewers determined that the requested medication is medically necessary for treatment.Credentials/Qualifications: One reviewer is board certified in gastroenterology and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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:  An enrollee has requested autonomic nervous system function testing for evaluation of her medical condition.  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  This patient had autonomic symptoms that had led to four prior hospitalizations.  In cases such as these, autonomic testing, including the tilt table test, is reasonable and standard of care to further evaluate the etiology of the described symptoms.  In this case, this testing led to a diagnosis while excluding other potential etiologies of the patients symptoms.  All told, autonomic nervous system function testing was likely to have been of greater benefit than other available modalities.  Final Result: Two 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:  All three reviewers are board certified in neurology 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.