Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laparoscopic sleeve gastrectomy. The records provided for review document that this patient has a BMI that is 35 kg/m2 without documentation of an associated serious obesity-related comorbid condition to support an indication for the requested bariatric surgical procedure (Mechanick, et al.). The patient has obtained surgical clearances from her dietary and behavioral health providers. However, there is no report of a serious obesity-related condition such as type 2 diabetes mellitus, hypertension, or obstructive sleep apnea to support severe obesity and laparoscopic sleeve gastrectomy. On sleep study, the patient was found to have disordered breathing without evidence of sleep apnea. All told, the requested laparoscopic sleeve gastrectomy is not medically necessary for treatment of this patient.Final Result: The reviewer 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: The reviewer is board certified in surgery with expertise 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 patient has requested authorization and coverage for Entresto 97 mg-103 mg. Findings:  The physician reviewer found that the records provided for review, this patient has a cardiomyopathy and dyspnea but no documented left ventricle ejection fraction (LVEF) below 40% at any time. The patients recent LVEF was 55% with no documented findings of congestion on physical examination. In the clinical circumstance of LVEF of 41% or greater, the records do not support an indication for treatment with Entresto. Entresto is not recommended for patients with heart failure and LVEF greater than 40%. All told, the requested Entresto 97 mg-103 mg is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication 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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a full electric bed with air mattress, full length side rails, and rail pads.The submitted records do not support that the requested equipment is medically necessary. In this case, the patient has severe cognitive and physical impairments in the aftermath of bilateral strokes. The patient has positioning needs due to immobility with susceptibility for skin and soft tissue breakdown (i.e., pressure injury risk), as well as for feeding due to aspiration risks. With respect to a bed, these positioning needs can be met with a semi-electric hospital bed with an appropriate mattress surface (Gillespie, B., et al.; Chew, H-S., et al.). A total electric hospital bed would also include electric height adjustment. This feature can be necessary for persons who require this feature for independent transfers into and out of the bed. In the current case, however, this powered bed height adjustment feature is not necessary because the patient uses a mechanical lift device for dependent transfers. Height adjustment on a hospital bed is otherwise considered a convenience feature. If height adjustability is desired for the caregiver's comfort while providing care, a bed with manual adjustability (e.g., via crank) can be an option. Under these circumstances, the requested full electric bed with air mattress, full length side rails, and rail pads is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested equipment is not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 Enteric Pathogens Panel. The American Academy of Family Practice guidelines for the evaluation of acute diarrhea do not recommend the use of polymerase chain reaction (PCR) assays. These tests do not discriminate between viable and non-viable organisms and can detect microbes at nonpathogenic levels. Given the high rates of asymptomatic carriage of enteropathogens, this can be a considerable problem. Moreover, the relative importance of each pathogen may be unclear. Per the guidelines from the Infectious Diseases Society of America (IDSA), a gastrointestinal pathogen panel is not recommended in cases of diarrhea without complications such as fever or hematochezia. This patient presented with diarrhea without complications such as fever or hematochezia. Evaluation for parasites and Clostridium difficile in May 2020 at the onset of her symptoms were negative. Thus, the Enteric Pathogens Panel was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Enteric Pathogens Panel was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma molecular profiling gene test. Based on the patients American Joint Committee on Cancer (AJCC) clinical stage, she has a five-year and 10-year melanoma survival rates of 99% and 98%, respectively (Gershenwald, et al.). The DecisionDx-Melanoma molecular profiling test was performed and yielded a Class 1A score, consistent with the lowest risk of recurrence within five years. Based on the gene expression profiling score alone, the patients five-year melanoma specific survival is as high as 100%, signifying a relatively equivalent prognosis for the patient. Currently, there is a paucity of peer-reviewed medical literature demonstrating improved patient health outcomes with use of the DecisionDx-Melanoma assay when compared to standard risk profiling. In the absence of data obtained from prospective randomized controlled trials showing some measurable clinical benefit, the National Comprehensive Cancer Network (NCCN) does not recommend the DecisionDx-Melanoma for routine use. Thus, the DecisionDx-Melanoma molecular profiling gene test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the DecisionDx-Melanoma molecular profiling gene test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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: Physician reviewers 1, 2, and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Transurethral destruction of prostate tissue by radiofrequency generated water vapor thermotherapy (CPT 53854 and 0360). Radiofrequency generated water vapor thermotherapy with Rezum is a novel technique to treat male urinary symptoms secondary to benign prostatic hyperplasia (BPH) due to an enlarged prostate. McVary and colleagues reported that their sham-controlled trial showed improved storage and voiding symptoms after the thermal therapy procedure. Overall, current medical literature does not support improved efficacy of Rezum procedure over current standard of care consisting of transurethral resection of prostate (TURP). In addition, long-term outcomes of radiofrequency generated water vapor thermotherapy have not been established. Hence, although the Rezum procedure is a promising procedure for treatment of BPH, it is not considered standard of care for treatment of BPH refractory to medical therapy. For these reasons, the transurethral destruction of prostate tissue by radiofrequency generated water vapor thermotherapy (CPT 53854 and 0360) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the transurethral destruction of prostate tissue by radiofrequency generated water vapor thermotherapy (CPT 53854 and 0360) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the 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: Physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan (CPT codes 78815, 78451, and HCPCS codes A9552, A9526, A9502). Based on the records for review, this patient has biopsy proven sarcoidosis. The patients cardiac magnetic resonance imaging (MRI) did not show cardiac involvement. However, MRI was performed in 2015, and the patient has since developed cardiac symptoms including palpitations and presyncope. In addition, she has intermittent arrhythmias on monitoring and conduction disease on electrocardiography, which can be manifestations of cardiac sarcoidosis. Cardiac involvement has been demonstrated in up to 25% of patients with systemic sarcoidosis. Moreover, the patients treatment plan would likely change and be intensified should the PET scan confirm cardiac involvement. For these reasons, the requested PET scan (CPT codes 78815, 78451, and HCPCS codes A9552, A9526, A9502) is medically necessary for evaluation of this patient. 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 internal medicine with subspecialty certification in cardiovascular disease 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: The patients parent has requested authorization and coverage for in-home private during nursing home services. Kuo and colleagues noted that the parents of medically complex children with special health care needs spend an average of nearly nine hours per day managing the patients basic healthcare needs, such as personal hygiene and feeding, administering drugs and managing symptoms, pain and sleep related problems during the night. Current data shows that the number of medical appliances and the status of single caregivers correlated proportionally with a greater amount of time needed for the patients care. It is important for patients families to receive appropriate support with daily care tailored to the patients individual needs. In this case, this patient has multiple chronic conditions and functional limitations that make her dependent on caregivers and the use of complex medical appliances. This patients mobility, breathing, and feeding problems require constant assistance to cope with her functional limitations. For these reasons, the requested in-home private during nursing home services are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for quantity increase for the medication, rizatriptan 10 mg orally disintegrating tablets, to 15 tablets per 30 days. This patient presents with a history of tension type and migraine headaches. The patient currently takes acetaminophen, narcotics, triptans, and NSAIDs to control his headaches. The patient reports that Maxalt 10 mg disintegrating tablets in combination with Tylenol #3 provides mild relief. Rizatriptan is commonly used as an abortive medication for the treatment of migraines. As per the recommended dosing protocols, patient should not take more than two tablets during a 24-hour period. Furthermore, no more than nine tablets should be taken per month. If more than nine tablets of rizatriptan are required, then the patients migraines are uncontrolled and require an increase in the dosage of prophylactic medications. As such, the patient should be placed on prophylactic medications such as topiramate or amitriptyline to help control headaches. Providing a higher number of rizatriptan tablets is not consistent with the standard of care as it can pose a cardiac risk due to diffuse vasoconstriction. Therefore, a quantity increase for the medication, rizatriptan 10 mg orally disintegrating tablets, to 15 tablets per 30 days is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 neurology 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 Coflex Interlaminar Stabilization surgical procedure. Interspinous process decompression offers an intermediate step in the continuum of care for patients with neurogenic intermittent claudication associated with lumbar spinal stenosis. The Coflex device is made of a titanium alloy and designed to fit between two adjacent spinous processes in the lumbar spine. The FDA approved indications for Coflex is one- or two- level lumbar stenosis from L1 to L5 producing at least moderate impairment in skeletally mature patients who have failed six months of conservative treatment. The presence of back pain does not exclude a patient from undergoing treatment with Coflex. However, axial back pain alone without leg, buttock, or groin pain has not been demonstrated to provide the patient positive results. This patient has lumbar spinal stenosis with neurogenic claudication. The provider recommended decompression and implantation of a Coflex device. However, high quality studies have failed to demonstrate efficacy of this implant in improving mid- to long-term outcomes over decompression alone. Accordingly, the requested Coflex Interlaminar Stabilization surgical procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Coflex Interlaminar Stabilization surgical procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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

An enrollee has requested authorization and coverage for Synvisc-One injection for both knees.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, including corticosteroid injections, with the alternative being bilateral total knee arthroplasties in the presence of mild to moderate osteoarthritis. Under these circumstances, the requested Synvisc-One injection for both knees is medically necessary to treat the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested authorization and coverage for Xifaxan 550 mg tablets (42 tablets for 14-day supply). Menees and Chey found that recent studies have demonstrated that an imbalance in gut bacterial communities, or dysbiosis, may be a contributor to the pathophysiology of irritable bowel syndrome (IBS). Ponziani and colleagues found that rifaximin was a safe antibiotic for gut microbiota modulation in patients with IBS, while Gatta and Scarpignato noted that rifaximin also seemed to be effective and safe for the treatment of small intestinal bacterial overgrowth (SIBO). In this case, the patient has documented overgrowth of certain bacteria and symptoms such as bloating that are associated with IBS. Xifaxan is effective in treating these symptoms, with few adverse events and is medically indicated for this patient. Therefore, Xifaxan 550 mg tablets (42 tablets for 14-day supply) are medically necessary for the treatment of this patient.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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gelsyn-3 injection series for the left knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Gelsyn-3 injection series for the left knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.