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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin 20 mg/2 mL pen injector capsule for treatment of his short stature. Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The requested medication is not medically necessary for treatment of the patients medical condition. Based on the patients growth curve, he has reached mid parental height which appears to be 67 inches, + or -4 inches. The patient is now already 67.5 inches, and growth hormone supplementation is not medically indicated as he has reached his genetic potential. In addition, there is a lack of data provided of his height velocity prior to age 14. Accordingly, it is not possible to make a clinical determination as to whether he had normal height velocity or less than normal height velocity prior to age 14. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 CPT code 78815 - positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh for evaluation of her breast cancer. Findings:  The physician reviewer found that this patient has had routine post treatment mammography and the most recent demonstrated no evidence of recurrence. The patients most recent PET/CT showed no sign of malignancy. There are no clinical findings to suggest tumor recurrence per the submitted records and no imaging studies suggestive of same to warrant follow-up. The National Comprehensive Cancer Network (NCCN) guidelines are specific in that there is no recommendation for surveillance imaging or lab tests absent a clinical finding to suggest tumor recurrence or metastatic disease. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the L5-S1 anterior lumbar discectomy, anterior interbody fusion with PEEK cage Medtronic demineralized bone matrix, allograft bone chips L5-S1, posterior left L3-4 laminotomy for sub-lamina approach right L3-4 foraminal discectomy, L2-3 lumbar drain insertion, with stereotactic navigation performed on and three (3) day inpatient hospital stay provided . Findings:  The physician reviewer found that ss noted by a study, lumbar fusion is a commonly performed procedure for the treatment of painful instability of the spine, usually manifest as chronic low back pain. This patients records document a history of low back pain with L5-S1 disc degeneration. However, there is no documentation of any evidence of instability, fracture, or tumor. The current established criteria for lumbar fusion surgery have not been met based on the records provided for review. Accordingly, the L5-S1 anterior lumbar discectomy, anterior interbody fusion with PEEK cage Medtronic demineralized bone matrix, allograft bone chips L5-S1, posterior left L3-4 laminotomy for sub-lamina approach right L3-4 foraminal discectomy, L2-3 lumbar drain insertion, with stereotactic navigation performed and three (3) day inpatient hospital stay provided were not medically necessary for treatment of this 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 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 reimbursement for AmniSure rupture of membranes (ROM) testing for evaluation of her suspected possible ROM. Findings:  Three physician reviewers found that AmniSure ROM testing has been recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid if these tests are inconclusive. AmniSure is not recommended as a first-line test. The study compared AmniSure with standard methods for diagnosing rupture of fetal membranes. The authors noted false-positive test result rates of 19-30% in patients with clinically intact membranes and symptoms of labor. Given that the patients records do not document that she underwent standard testing with pooling, ferning and nitrazine testing of vaginal fluid, the AmniSure ROM testing performed on 7/11/16 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 testing at issue was 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 obstetrics and gynecology 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 authorization and coverage for radiofrequency neurolysis for treatment of her sacroiliitis. Findings:  Two physician reviewers found that overall, there is lack of evidence to permit conclusions on net health outcomes in well-designed randomized controlled trials with adequate follow-up regarding radiofrequency ablation for SI joint pain. Researchers demonstrated no high-quality evidence suggesting that radiofrequency denervation provides pain relief for patients with chronic low back pain. Other researchers performed a systematic review with analysis. The authors stated that evidence of moderate quality exists on therapeutic procedures, but it is insufficient to determine the indications and effectiveness of sacral lateral branch thermal radiofrequency neurotomy, and more research is required. All told, there is paucity of data to support the requested radiofrequency neurolysis as 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 procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in orthopedic surgery and 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 digital breast tomosynthesis for a breast examination. Findings:  Three physician reviewers found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, the patients breast tissue was described as heterogeneously dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense tissue that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The reviewers determined that the service 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, 2, and 3 are board certified in diagnostic radiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the sacroiliac (SI) joint fusion with three day inpatient hospital stay for treatment of her left SI joint arthrosis and left sacral ala and left S1 neural foraminal degenerative cyst. Findings:  The physician reviewer found that based upon a review of the medical records, the primary pathology in this case was S1 radiculopathy due to a 3 cm cyst of the sacrum. The radiculopathy had recurred despite previous surgery consisting of a sacral laminectomy. This necessitated resection of a portion of the sacrum with excision of the cyst which resulted in instability. Given the instability, SI fusion was indicated for stabilization of the SI joint. Although minimally invasive surgery is preferred for the SI joint, in this case, and the pathology was different. Therefore, the stabilization performed was appropriate. The three days hospitalization was necessitated for post-operative pain control and was also reasonable. As noted by researchers, minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. 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 orthopedic surgery 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 medial branch radiofrequency ablation for treatment of his back pain. Findings:  Two physician reviewers found that the patient reportedly received bilateral diagnostic medial branch blocks on two different occasions, with significant temporary benefit.  He also is diagnosed with a radiculopathy for which transforaminal epidural steroid injections were provided and reportedly beneficial.  However, the records do not document reduction in the use of opioid analgesic medication despite the reported benefit.  The procedure note provided for the lumbar radiofrequency ablation describes localizing landmarks in the cervical spine and unspecified levels.  The documentation describes a cervical spine radiofrequency ablation being performed, which is not appropriate to treat lumbar spine pain.  The records were inconsistent, as the wrong part of the spine was noted in the procedure note.  There is a lack of support for the services at issue in this clinical setting.  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 21, 2, and 3 are board certified in physical medicine with sub-specialty certification in pain medicine 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic nephrectomy. Findings:  The physician reviewer found that the patient has presents with symptomatic left flank pain related to her massively enlarged left polycystic kidney. The left kidney is severely hydronephrotic and massively enlarged with no distal obstruction noted on imaging. Normal renal parenchyma is also not seen on ultrasound and CT imaging. It is the standard of care to perform a laparoscopic nephrectomy for symptomatic pain polycystic kidney, especially if there may be potential added pathology such as severely hydronephrotic or obstruction from a mass. However, it is important to determine why the left kidney is severely hydronephrotic or obstructed or if there is a solid mass to rule out cancer causing this obstruction. The referral to an in-network urologist at USC Keck is medically reasonable as the provider may pursue further work-up such as a CT urogram, magnetic resonance imaging (MRI) or a split renal scan, discuss the possible benefits of laparoscopic nephrectomy in the setting of a massively large left kidney, and the reduction in estimated glomerular filtration rate (eGFR) when left nephrectomy is performed. Of note, the patient does not have kidney failure, her creatinine is noted to be 1.0 with eGFR of 63, and performing a left nephrectomy will significantly reduce her eGFR, depending on how much function the left kidney is contributing. Therefore, the request for laparoscopic nephrectomy is not medically necessary for treatment of the patients medical condition at this time.Final Result: The reviewers determined that the requested surgery is not medically necessary at this time for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld at this time. Credentials/Qualifications: Physician reviewer is board certified in 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 platelet rich plasma injection for treatment of his elbow pain. Findings:  Two physician reviewers found that The submitted documentation fails to demonstrate the superior efficacy of the requested services.  This patient presented with complaints of left elbow pain.  His symptoms were worse with grasping/gripping and lifting, and improved with rest. Clinical examination findings documented medial epicondylar tenderness and pain with resisted arm motion.  X-rays demonstrated mild humeroulnar osteoarthritis.  The patient was diagnosed with primary left elbow osteoarthritis and partial tear of the common flexor tendon. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has not been submitted.  The current medical evidence does not support the requested services in this clinical setting.  There is a lack of evidence that conservative treatment had failed.  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: Reviewers 1, 2, an 3 are board certified in orthopedic surgery 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400 mg  100 mg. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival . For these reasons, Epclusa is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Physician reviewer is board certified in internal medicine with sub-specialty 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An has requested reimbursement for 10 transcranial magnetic stimulation (TMS) sessions for treatment of her major depressive disorder. Findings:  The physician reviewer found that Transcranial Magnetic Stimulation is a novel, noninvasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population.  A typical treatment course of transcranial magnetic stimulation consists of 30 to 40 sessions spanning four to six weeks.   At this time, there is a lack of adequately powered, controlled studies showing the benefit of longer courses of transcranial magnetic stimulation therapy.  The medical literature does not support a reasonable expectation that additional transcranial magnetic stimulation therapy would have improved the patients condition or prevented a more serious episode of illness.  Further, there is a lack of evidence in the literature to suggest that the patients marginal improvement was more than likely due to the additional transcranial magnetic stimulation sessions.  Finally, it appears that the patient was neither prescribed antidepressant medication nor active in psychotherapy, which represent trusted first-line interventions in the treatment armamentarium for major depressive disorder. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of his chronic hepatitis C virus genotype 4. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive genotype 4 patients, based on the ASTRAL-1 trial, which showed 100% cure rate. Delay in treatment may result in decreased survival. 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 internal medicine with sub-specialty 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.