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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (BRCA testing) Findings:  The physician reviewer found that this patient is a candidate for risk assessment and genetic testing. The patient is of Ashkenazi ancestry and has a first degree relative with cancer. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, pancreatic and gastric cancers (Tai, et al; Ferrone, et al). In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. Given this patients indication for testing, the gene test (BRCA testing) was likely to have been more beneficial for evaluation of this patients medical condition than standard available testing. Findings:  Three physician reviewers found the gene test (BRCA testing) was likely to have been more beneficial for evaluation of this patients medical condition than standard available testing.Final Result: The reviewers determined that the gene test (BRCA testing) was likely to have been more beneficial for evaluation of this patients medical condition than standard available testing.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with subspecialty certifications in medical oncology and hematology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty 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: The enrollee has requested authorization and coverage for Supartz injections one each knee. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Medical literature shows on a systematic review of meta-analyses comparing hyaluronic acid injections with other non-operative treatment modalities for knee osteoarthritis. The authors found that intraarticular hyaluronic acid improves knee pain and function. Researchers noted that the benefits of intraarticular hyaluronic acid on knee osteoarthritis may include mechanical viscosupplementation of the joint andthe re-establishment of joint homeostasis through induction of endogenous HA [hyaluronic acid] production, which continues long after the exogenous injection has left the joint. Moreover, hyaluronic acid injections have been shown to have a good safety profile. All told, the requested Supartz injections one each knee are medically necessary for treatment of this patients bilateral knee osteoarthritis. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for a series of Orthovisc injections. The submitted documentation supports that the requested services are medically necessary. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As noted by researchers, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. Another study performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, the requested Orthovisc injections are medically necessary to treat the patients medical condition at this time.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections. Researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Researchers concluded that repeated cycles of intra-articular sodium hyaluronate treatment was found efficacious in delaying a total knee replacement in patients with knee osteoarthritis that failed conservative treatment. The findings were documented from a 54-month follow-up period.In this case, the patient presents with chronic bilateral knee pain. The patient's functional limitations are noted in activities of daily living and recreational pursuits. The patients clinical examination findings and radiographic findings have been consistent with mild to moderate bilateral knee osteoarthritis. Reasonable conservative treatment, including activity modification, NSAIDs, cortisone injections, and ice, have failed to provide adequate symptom relief. The patient has undergone two prior series of Orthovisc injections to both knees with reported excellent symptom relief and improvement in activity tolerance for 6 months or longer. Evidence-based, medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee as safe and effective and better than corticosteroid injections. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the requested Orthovisc injections to both knees are medically necessary for treatment of the 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for peripheral nerve block injection.Findings:  Three physician reviewers found that there is a lack of support for the requested services in this patients case. The records document hypertension, type 2 diabetes mellitus and peripheral neuropathy. The patient reported pain and numbness in her feet. She has been prescribed Norco for pain. The records do not document trials of other oral pain medications for neuropathic pain. The American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine noted peripheral somatic nerve blocks should not be used for long-term treatment of chronic pain.  Evidence-based clinical practice guidelines do not support the use of peripheral nerve blocks for neuropathy. In this patients case, the records do not document trials of oral anticonvulsants or other medications that are used to treat peripheral neuropathy. Therefore, the requested peripheral nerve block injection is not likely to be superior over other 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 anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient residential treatment services. Findings:  The physician reviewer found that The American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay, moving from program-driven to clinically driven and outcomes-driven treatment. The ASAM criteria is a set of objective guidelines used by clinicians to assist with treatment planning and advocates for service intensity provided in the least intensive but safe treatment setting.In this case, on admission, the patient had no symptoms of withdrawal and was not at imminent risk for withdrawal. He was not a danger to himself or others. There were no emotional, behavioral, or cognitive barriers to providing this patient with the treatment at a lower level of care. The patient reported that his pattern of use was not daily. He was ordered no medications except for ibuprofen and acetaminophen as needed. There was no evidence of a high degree of impulsivity, aggression, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care.The patient was motivated and appeared to be compliant with the program. He was accepting the principles of treatment and involving himself in his recovery. His parents were supportive and involved in his recovery. Psychiatrically, the patient did not require the containment of a 24-hour/seven days per week environment with 24-hour/seven days per week medical and nursing monitoring. The patient recognized his triggers and the negative consequences of his behavior and was progressing well in working the steps outlined in Alcoholics Anonymous. He was receptive to learning new coping skills for relapse prevention.Relapse risk is inherent in this population and is not a reason to keep a patient in this setting. There was nothing to suggest that the patient could not have been treated in an ambulatory setting at a lower level of care in conjunction with community-based supports, such as the 12-step program with a sponsor. Therefore, the inpatient residential treatment services provided to the patient were not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Oxycodone 10 mg and Oxycontin ER 40 mg. Findings:  The physician reviewer found that currently, the Centers for Disease Control and Prevention (CDC) guidelines do not support the long-term use of opiates for chronic non-malignant pain. In the peer-reviewed medical literature, which studied women with chronic pelvic pain, the authors found poor outcomes with chronic opiate therapy. The authors noted that chronic opiate therapy is not recommended for patients with chronic pelvic pain. All told, the requested Oxycodone 10 mg and Oxycontin ER 40 mg are not medically necessary for treatment of this patients chronic pain. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 biofeedback (CPT code 90911). Urinary incontinence is a medical condition that significantly reduces quality of life. Nonsurgical therapy for urinary incontinence is recommended by specialists in urogynecology. Effective first-line treatment options supported in the medical literature include biofeedback techniques. Biofeedback has been shown to reduce symptoms and help patients avoid surgical interventions. In this case, the patient has reported improved symptoms with pelvic floor physical therapy. The addition of biofeedback to pelvic floor physical therapy is likely to provide this patient with even more effective relief of her symptoms. All told, biofeedback (CPT code 90911) is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Findings:  Three physician reviewers found that biofeedback (CPT code 90911) is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the biofeedback (CPT code 90911) is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a magnetic resonance imaging (MRI) of the lumbar spine. Findings:  The physician reviewer found that in patients with lower back and leg pain, lumbar foraminal stenosis is an important consideration, especially in the presence of radicular symptoms, such as this patients shooting leg pain and weakness. Foraminal stenosis can develop as a result of progressing degenerative disc disease and can cause low back and leg pain with extension of the lumbar spine. Oftentimes, there is a lack of critical clinical findings in these cases and imaging is needed. In patients with chronic low back and persistent leg pain, imaging to evaluate for lumbar spinal stenosis is the standard of care. Radiological diagnosis is performed using multiple radiological modalities, particularly the lumbar MRI. Electrophysiological testing can also aid diagnosis, but is not as specific as MRI. In the medical literature, the authors noted that MRI is instrumental in the diagnosis of ligamentum flavum thickening associated with facet degeneration, which causes spinal stenosis. In light of the foregoing, the requested MRI scan of the lumbar spine is medically necessary for evaluation of this patients low back and radicular pain.Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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 the enrollee has requested reimbursement for the cytogenetic microarray testing. The clinical utility of chromosomal microarray is well established, and is now considered first-line genetic testing for patients with developmental delays and autism spectrum disorders. In a study by researchers, a retrospective chart review of chromosomal microarray testing was performed on patients with developmental delay, intellectual disability, autism spectrum disorders and congenital anomalies. Findings in this study demonstrated that chromosomal microarray results influenced medical care in the majority of patients by precipitating medical referrals, diagnostic imaging, or specific laboratory testing. Thus, there is adequate support for chromosomal microarray analysis in this patients evaluation given the concern for intellectual disability. For these reasons, the cytogenetic microarray testing was likely to be more beneficial for evaluation of this patients medical condition than any available therapy.One reviewer found that the cytogenetic microarray testing was not likely to be more beneficial for evaluation of this patients medical condition than any available therapy.Final Result: Two of the three 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:  One reviewer is board certified in genetics with subspecialty certification in clinical cytogenetics and is actively practicing. One Reviewer is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing.  One Reviewer is board certified in pediatrics and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy. The submitted documentation does not support that the requested service is medically necessary. Enns and colleagues performed a systematic literature search of studies on the use of capsule endoscopy. They concluded that capsule endoscopy should be considered a complimentary test in patients with GI bleeding, Crohns disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies. In this case, based on the limited clinical information provided, there is no indication of the need to perform a wireless capsule endoscopy in this patient. There are no signs or symptoms of unexplained GI blood loss. There is no clinical evidence that the patient has a small bowel neoplasm or other indication for the capsule. Under these circumstances, wireless capsule endoscopy is not medically necessary for the patients medical condition.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 internal medicine, with subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator. In the peer-reviewed medical literature, it is concluded that upper airway stimulation is a nonanatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA [obstructive sleep apnea] who have failed nasal continuous positive airway pressure. However, this patients trial and failure with continuous positive airway pressure is not well documented in the records provided for review. In addition, the patient has periodic limb movement sleep disorder and insomnia as well as moderate obstructive sleep apnea. According to the current data, these sleep related comorbidities have not been studied in trials for hypoglossal nerve stimulator implantation. For these reasons, the requested hypoglossal nerve stimulator is not likely to be more beneficial for treatment of the patients medical condition than any standard therapy.One reviewer found that the requested hypoglossal nerve stimulator is likely to be more beneficial for treatment of the patients medical condition than any standard therapy.Final Result: Two of the 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:  One reviewer is board certified in otolaryngology with subspecialty certification in plastic and reconstructive surgery and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology with subspecialty certification in sleep medicine 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.