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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne testing for evaluation of the enrollees metastatic melanoma. Findings:  Two of the three physician reviewers found that FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the provider as to which chemotherapeutic drug would be useful.  However, there is a lack of convincing evidence that the assay adds to the decision making ability or yields a result that is reliably clinically beneficial.  There are a variety of non-randomized studies exploring the value of molecular provider. One study noted this ongoing research as well as the serious limitations of such studies. Finding the presence of a mutation does not guarantee that a treatment directed at that mutation will produce a clinically beneficial response. Final Result: The 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Inspire Upper Airway Stimulation treatment for treatment of the enrollees obstructive sleep apnea (OSA). Findings: The physician reviewer found that the request for the Inspire Upper Airway Stimulation treatment is medically necessary for treatment of the patients medical condition. There is sufficient peer-reviewed literature supporting hypoglossal nerve implantation for the treatment of OSA. The proposed procedure is supported as a successful and appropriate long-term treatment for individuals with moderate to severe OSA. In this case, the patient has failed CPAP therapy, is status post UPPP with an AHI of 54. Final Result: The reviewer determined that the requested service 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 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 radiofrequency neurolysis of the sacroiliac joint.Findings:  The physician reviewer found that the patient is diagnosed with lumbar spondylosis. The underwent bilateral L3-S1 facet joint injections. The injection was done with fluoroscopic guidance and conscious sedation. This was his third injection. There had been 40% relief after the first and second procedure. He had pain rated at 8/10. Facet injections had provided 50% pain relief lasting for only three days. He wanted to discuss his worsening pain. His relevant past medical history included chronic pain and gastroesophageal reflux disease. Physical examination findings included a body mass index of 28. There was no sacroiliac joint tenderness. There was a normal neurological examination. The patient requested coverage for radiofrequency neurolysis of the sacroiliac joint. Per the Health Plan the requested services are investigational for treatment of this patient.  The safety and/or effectiveness of this procedure have 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 sacroiliac pain and to determine the potential candidates and treatment parameters as there is no standardized technique. Radiofrequency treatment is a minimally invasive procedure that has been used for over three decades in treating various chronic pain syndromes such as trigeminal neuralgia, post-herpetic neuralgia, low back pain, and complex regional pain syndrome/reflex sympathetic dystrophy. However, it is a palliative treatment not without complications. Radiofrequency procedures have been reported to be associated with high number of complications compared with other ablative neurosurgical techniques. In terms of this patients condition, he has not exhausted conservative therapy. Conservative treatment such as medication management, compliance with a home exercise/management program, and/or chiropractic care are among the current recommendations. Therefore, radiofrequency neurolysis of the sacroiliac joint is not likely to be more efficacious than the standard options for treatment of this patient. Final Result: The reviewers determined that the requested services are 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 reviewer 1,2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewers are 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 residential mental health and substance use treatment program for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patient had mild withdrawal symptoms and had been started on the Librium taper in her emergency room visit, which did not require residential level of care to continue. She showed no evidence of being a danger to self or others. She was cognitively intact and was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  She was medically and psychiatrically stable.  She had prior treatments with an extended period of sobriety (nine months). She had experience in the 12 step process with a sponsor, even though she had continued drinking.  She was motivated. Relapse risk is inherent in the substance abusing populations and cannot be the sole reason for residential treatment. This patient did not require 24 hour per day, 7 days per week supervision.  She could have received treatment at a lower level of care. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDX melanoma gene assay performed. Findings:  The physician reviewers found that The patient has melanoma. Two lesions in the posterior neck area were excised. Pathology showed these were malignant melanoma arising out of a nevus with 0.2 mm depth of invasion. A sample of the tissue was submitted for the DecisionDX melanoma gene assay. The patient has requested reimbursement for the DecisionDX melanoma gene assay performed. The Health Plan denied reimbursement for the services at issue as investigational/experimental for the evaluation of this patients medical condition. The data on the DecisionDX test for melanoma has not made it part of routine analysis after sentinel lymph node biopsy. The two prospective studies have been discussed within the National Comprehensive Cancer Network (NCCN) and it has been concluded that the patients analyzed were a high risk cohort. There has also been some lack of consistency between various genes being used as biomarkers. As such, this test is very novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. This was also the consensus opinion of the NCCN guidelines. All told, DecisionDX melanoma gene assay performed was not likely to have been of more effective than the available standard therapy for the evaluation of this patients medical condition.Final Result: The 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 upheldCredentials/Qualifications: Physician reviewers 1,2 & 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. Each 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 removal of excess skin and tissue beneath the thighs and buttocks. Findings:  The physician reviewer found that the medical documentation provided for review does not demonstrate that surgical treatment of the proposed areas meets medical necessity criteria. Although the submitted photographs show significant excess skin of the medial thighs and there is some suggestion of functional impairment, specific conservative management has not been adequately documented.  Further, the photographs provided show only mild excess skin of the buttocks. As such, the medical necessity of removal of excess skin and tissue beneath the thighs and buttocks has not been established.With regard to whether the requested services meet reconstructive surgery criteria, the patients excess skin following weight loss is considered an abnormal structure of the body caused by obesity, a disease. The proposed procedures would be to create a more normal appearance. The surgery is likely to provide more than a minimal improvement in the appearance of the patients medial thighs, but not for the buttocks. The patient has significant excess skin of the medial thighs and correction would provide more than a minimal improvement in appearance of the thighs. However, this is not the case for the buttocks. As such, correction to the buttocks would not provide more than a minimal improvement in appearance. Therefore, based on the documentation provided for review, the request for removal of excess skin and tissue beneath the thighs has been established as reconstructive in nature for treatment of the patients medical condition, but reconstructive in nature for the patients buttocks. Final Result: The reviewers determined that a portion of the requested surgery is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis 5 mg for treatment of his enlarged prostate with lower urinary tract symptoms. Findings:  The physician reviewer found that the records provided for review document that this patients irritative lower urinary tract symptoms and erectile dysfunction were improved substantially with Cialis. His urinary tract symptoms have been treated with multiple medications including alpha blocker therapy and finasteride. His symptoms have been resistant to treatment. However, his urinary tract symptoms have responded to daily Cialis. Although this is considered a third-line therapy, it is has been successful for this patient following failure of first- and second-line therapies. Furthermore, daily Cialis has reportedly helped his erectile dysfunction. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in urology 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 Botox injection for treatment of the enrollees right foot dystonia. Findings: Two of the three physician reviewers found that Botox is considered standard of care for focal dystonia including dystonia of the foot. Undertreated focal foot dystonia can place the patient at undue risk of fall, trauma, and further impairment. In this particular case, the patient has a documented diagnosis of foot dystonia. A trial of Botox would be reasonable for this patients diagnosis. Final Result: The reviewers determined that the requested service 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the MyRisk genetic test for evaluation of the enrollees ductal carcinoma in situ (DCIS). Findings: Two of the three physician reviewers found that 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 was 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 including the Amsterdam criteria and the Bethesda consensus guidelines. These guidelines are highly focused on patients with colorectal cancer who have microsatellite instability although the occurrence of microsatellite instability in other Lynch syndrome associated tumors was discussed. The most common extra-colonic cancer in Lynch syndrome is endometrial cancer followed, in no particular order, by ovarian, gastric, renal (kidney), small intestine, pancreas, hepatobiliary, and ureteral. The MyRisk panel was appropriate for this patient since her current clinical situation may be caused by several potential cancer causing genes. Final Result: The reviewers determined that 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: Reviewers 1 and 2 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. Reviewer 3 is board certified in clinical 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for subcutaneous hormone pellet therapy for treatment of the enrollee, who reported fatigue, memory disturbance and insomnia. Findings: All three physician reviewers found that the medical evidence does not support the services at issue in this clinical setting. Testosterone pellets are compounded products which are not produced by any pharmaceutical company and are not approved by the U.S. Food and Drug Administration (FDA). There are many FDA-approved treatments available for menopausal symptoms. However, this patient has not reached menopause. Her hormone testing was normal, with no evidence of perimenopause, and normal testosterone levels. In addition, fatigue and insomnia is multifactorial, and there is no evidence in the record of any evaluation or attempts at therapy other than testosterone pellet implants.  In this case, the patient repeatedly received high doses of testosterone which was likely to cause supraphysiologic levels and potential side effects. 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Urolift cystoscopy for treatment of the enrollees benign prostatic hyperplasia. Findings: All three physician reviewers found that the Urolift procedure is a novel, minimally invasive approach to treating benign prostatic hyperplasia that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials, including prospective, sham controlled, randomized studies, have shown that the Urolift procedure is safe and effective in relieving lower urinary tract symptoms due to benign prostatic hyperplasia without significantly compromising sexual function. Compared with transurethral resection of the prostate and photoselective laser vaporization of the prostate, the Urolift is minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in urology 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 foot inserts (removable, molded to Pt model, UCB type, Berkeley Shell) for treatment of the enrollees diabetes and plantar fasciitis. Findings: The physician reviewer found that shoe inserts and modifications are considered medically necessary in limited circumstances. Inserts and other shoe modifications such as lifts, wedges, arch supports and other conditions are indicated if they are on a shoe that is an integral part of a leg brace and are medically necessary for the proper functioning of the brace. Prosthetic shoes are considered medically necessary if they are an integral part of prosthesis for individuals with partial foot amputation. Orthopedic footwear that does not meet the stated criteria is considered not medically necessary. Review of current guidelines from the Centers for Medicare and Medicaid Services (CMS) does not support the requested foot inserts (removable, molded to Pt model, UCB type, Berkeley Shell) as medically necessary for treatment of this patients plantar fasciitis. Final Result: The reviewer determined that the requested equipment 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 podiatry 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.