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

Nature of Statutory Criteria/ Case Summary: EE is requesting authorization and coverage for balloon dilation of the Eustachian tubes. The enrollee has eustachian tube dysfunction. Her symptoms include inability to clear her ears, ear popping and bilateral ear pain without drainage. She complains of dizziness, recurrent and moderate in severity, with episodes typically lasting five months. Symptoms worsened with standing still. She has a history of ear pain associated with altitude changes and her ENT-Otolaryngologist diagnosed bilateral eustachian tube dysfunction. She underwent bilateral myringotomy. According to the record, the enrollee had repeated episodes of sinusitis. An audiogram was reported to be within normal limits. Records do not include evaluation of eustachian tube function, the enrollees ability to equalize pressure through Valsalva movement, or imaging studies. The medical literature specifies the use of balloon dilatation requires a definitive diagnosis of eustachian tube dysfunction. A study noted there was some benefit for eustachian tube dilatation for enrollees who have failed medical management. However, there is insufficient objective evidence in the record the enrollee had eustachian tube dysfunction. Additionally, the records show this enrollee had a successful outcome with the use of medical therapy. Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in otolaryngology and the other is board certified in otolaryngology and head and neck surgery 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for partial hospitalization program (PHP) services. Findings:  The physician reviewer found that the enrollee has diagnoses of depression, anxiety, and post-traumatic stress disorder. Prior to admission, she was attending intensive outpatient program (IOP) sessions and receiving Transcranial Magnetic Stimulation (TMS) therapy. She reported difficulty with sleep and night terrors. She has a history of eating disorder, in remission and self-cutting to stop panic attacks. She has a significant trauma history and four past suicide attempts. On admission to the PHP, goals included managing panic attacks and working through trauma that she experiences during her life. Per the mental health discharge summary, regarding her goals, the patient believes she succeeded in managing panic attacks, was able to process a significant trauma in her life and wants to live, which is a different view from when she first arrived in treatment. There is no evidence in the medical records of suicide risk assessment after initial evaluation, work on chronic suicidal ideations as one of the goals and/or possible change in a strategy with regard to addressing chronic suicidal ideations. In applying LOCUS level of care assessment tool, the patients composite score is 17, which correlates with high intensity, community-based services. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for breast reduction surgery. The enrollee had breast augmentation and is now experiencing back pain, requiring a back brace. She also complains of burning and pain to her chest.  A physical therapy letter indicates the size and heaviness of the enrollees breasts are affecting her entire body.Findings:  Notes by her physician describe the size of the current implants. There are no records of the previous surgery, and there is no indication as to what size implant would be desired. There are multiple records from pain management. It is not clear from review of the records if weight of the current implants is the total for both sides or for each, but even if half per side, they could cause discomfort for this enrollees body frame size. However, they would not be attributed as the causative agent for bulging and extruding discs in the cervical spine and lumbar spine, as well, from her neck to lower back. Notes indicate the enrollee also has a history of a fall and shoulder dislocation. A mastopexy/lift reconstruction procedure is not medically indicated in this case, as the enrollee does not have breast hypertrophy, she has large implants. Removing the implants, which are currently intact, and replacing them with other ones is not medically consistent treatment, since the implants are the source of pain. Even if smaller in size, they are still significant in weight. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is a board certified in plastic and reconstructive 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for Guardant360 Comprehensive Liquid Biopsy. The enrollee began to experience persistent hemoptysis and was subsequently diagnosed with non-small cell lung cancer.  A computerized tomography (CT) scan of the chest showed bilateral disease. Biopsies revealed adenocarcinoma.  She underwent four cycles of chemotherapy.  A positron emission tomography (PET) scan showed significant disease on the right side.  She worsened clinically with increased hemoptysis. She received radiation therapy for about one year.  She started on nivolumab and docetaxel afterwards.  She underwent therapeutic thoracentesis.  A CT scan subsequently showed mild enlargement of a nonspecific right middle lobe nodule.  When she presented to her oncologist for cycle 25 of docetaxel, she complained of left-sided chest wall pain. Physical examination revealed decreased breath sounds at the left lung base. The provider found progression in the right lung after reviewing CT imaging. The physician ordered Guardant360 testing. A biopsy would be performed if the results were negative.  The testing revealed no tumor-related somatic alterations.The Guardant360 is a blood-based liquid biopsy approach that analyzes circulating tumor DNA (ctDNA) and searches for actionable genetic mutations. This test is still in the research phase and has not become the standard of care to replace or precede tissue biopsy. There are no ongoing studies of the Guardant360 test specifically in stage IV lung cancer. To date, there is insufficient literature to support that liquid biopsy is as effective as tissue biopsy to be used to determine patients lung cancer diagnosis, prognosis and treatment therapy. Currently, there is ongoing research to advance the liquid biopsy assays and enhance its utility in molecular diagnostics and precision medicine for lung cancer. While liquid biopsy may replace tissue biopsy in the near future, it is not currently supported by literature and current guidelines to replace tissue biopsy as means of guiding cancer diagnosis. Final Result: Three of the three reviewers determined that the requested services were not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for mental health residential treatment center (RTC) services for diagnoses of depressive disorder, not otherwise specified, borderline personality disorder and rule-out post traumatic stress disorder. She was not sleeping or showering, had an inconsistent life style, and was having mood swings. While at RTC, the enrollee received individual, family, and group therapy. Life skills were taught and practiced with the help of the transition specialist. In addition, she was seen for monthly psychiatric evaluations. The Level of Care Utilization System (LOCUS) guidelines were applied in this case. The enrollees composite LOCUS score is 18, which correlates with high intensity, community-based services. Medical evidence does not support the services at issue in this clinical setting. Therefore, the requested RTC services that were provided were not medically necessary for the treatment of this enrollee.Final Result: The physician reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Supartz injections in both knees. Hyaluronic acids are naturally occurring connective tissues materials that help cushion and lubricate joints. Intra-articular injection of avian-derived or synthetic hyaluronic acid, also called viscosupplementation, can decrease osteoarthritis symptoms in some, but not all patients. The American Academy of Orthopaedic Surgeons (AAOS) guidelines do not recommend hyaluronic acid for patients with symptomatic osteoarthritis, based on strong evidence. In this case, the submitted clinical documentation does not support the use of viscosupplementation injections to treat the patients knee pain. The requested treatment is not endorsed by the AAOS due to lack of evidence supporting its efficacy. Therefore, the requested Supartz injections in both knees are not likely to be more beneficial for treatment of the patient's medical condition than any available 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 orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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: An enrollee has requested authorization and coverage for Stivarga. Findings:  Two of the three physician reviewers found that this patient has been treated with multiple modalities to control his osteosarcoma. The National Comprehensive Cancer Network guidelines note that there are several multi-agent chemotherapy regimens that can be used in this instance, and most of these regimens are off-label. Stivarga (regorafenib) is a multi-kinase inhibitor that has been approved by the U.S. Food and Drug Administration (FDA) for metastatic colorectal cancer, gastrointestinal stromal tumor, and hepatocellular carcinoma. A clinical trial demonstrated that regorafenib extended the progression-free survival compared to placebo. There is sufficient support for the requested medication for this patient who has exhausted other therapies. Therefore, Stivarga is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for minimally invasive/percutaneous sacroiliac (SI) joint fusion surgery. Findings: The physician reviewers found that the authors of a clinical trial on minimally invasive SI joint fusion using triangular porous coated implants in patients with SI joint dysfunction, due to degenerative sacroiliitis and SI joint disruption reported improved pain, disability and quality of life at 24-months. The procedure was associated with a decrease in opioid usage for SI joint or low back pain. Current guidelines require documentation of significant SI joint pain or limitations in activities of daily living because of SI joint pain; at least three positive SI joint provocative tests; and confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period. In addition, the patient should fail to respond to at least six months of conservative therapy; and alternative diagnoses have been ruled out. This patient presents with a history of bilateral SI joint pain. Functional limitations are noted due to SI joint pain in activities of daily living and work ability. He experienced 100% pain relief following a SI joint injection during the anesthetic phase. Moreover, he has failed to achieve adequate relief comprehensive conservative treatment. Therefore, the requested minimally invasive/percutaneous SI joint fusion surgery 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 requested services are 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 orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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: The patient has requested authorization and coverage for Orthovisc injections in the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. As such, Orthovisc injections in the left knee are medically necessary for management of this patients 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for the medication, H.P Acthar Gel. The enrollee has a history of steroid induced diabetes mellitus type 2, and systemic lupus erythematosus (SLE). Her nephrologist is requesting approval of HP Acthar Gel due to worsening proteinuria, now in the nephrotic range.  She has had previous unsuccessful treatments including steroids, CellCept, Plaquenil, and cyclosporine. Her physician indicates a renal biopsy showed immunoglobulin A (IgA) nephropathy. Current treatments are not managing her symptoms so her physician has prescribed Acthar with a goal of managing proteinuria with nephrotic syndrome. A kidney biopsy done showed focal segmental glomerulosclerosis associated with lgA nephropathy and/or prior lupus nephritis. According the medical literature, studies in enrollees with IgA nephropathy emphasize the importance of optimal use of supportive care to include weight normalization; control of blood pressure and proteinuria; use of renin-angiotensin systemblocking agents; and dietary restriction of sodium and protein intake. If these measures fail to control the disease, next steps, in general, involve the use of immunosuppression. In this study, which did not include H.P. Acthar gel, continuing supportive care was compared to various immunosuppression regimens. Only the corticoid monotherapy with prednisone group showed a reduction in proteinuria at twelve months. Serious side effects included impaired glucose tolerance.  The data suggesting that H.P Acthar Gel can be used as an alternative to prednisone in enrollees with IgA nephropathy is lacking. The reports of Acthar gel in IgA are not reliable reports. There was a small study of five enrollees with IgA and only two showed a partial response. The makers of H.P. Acthar Gel, in their safety report on the drug, indicate common adverse reactions for Acthar are similar to those of corticosteroids and include a change in glucose tolerance. In conclusion, there is insufficient clinical information in the medical record to support H.P. Acthar Gel as medically necessary to treat the medical condition reported.  The enrollee has been treated with appropriate maximal non-immunosuppressive therapy with a persistence of proteinuria only. Any reports of a positive response to Acthar gel, have very limited clinical data that does not support the true clinical role of this medication in IgA nephropathy.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is board certified in nephrology 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for LINX Reflux Management System procedure. The LINX device received U.S. Food and Drug Administration (FDA) approval for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. Although there is a need for comparative studies, available data suggests that LINX may provide long-term benefit in well-selected patients. Appropriate patient selection is crucial before anti-reflux procedures. Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. This patient has GERD as based on pH recording. However, the records document adequate management of GERD when he is compliant with taking acid blocker drugs. Since this patient can optimize the benefit from available standard therapy by optimizing compliance with daily Dexilant use as well as a lifestyle aimed at GERD prevention, the requested procedure is not indicated. Therefore, the LINX Reflux Management System procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested 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 internal medicine with subspecialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in gastroenterology 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.