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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lymphovenous bypass surgery (CPT 38999). The records provided for review document that this patient has a history of left lower extremity lymphedema secondary to prostate cancer. The patients provider has recommended treatment with lymphovenous bypass surgery. The consensus document from the International Society of Lymphology (ISL) states that lymphovenous anastomoses (LVA) have undergone confirmation of long-term patency and some demonstration of improved lymphatic transport. The ISL noted that, Multiple lymphaticovenous anastomoses in a single surgical site with both the superficial and deep lymphatics, allow the creation of a positive pressure gradient (lymphatic-venous) and evade the phenomenon of gravitational reflux without interrupting the distal peripheral superficial lymphatic pathways. Garza and Chang found that the benefits of the procedure include its effectiveness in treating early-stage lymphedema of either the upper or lower extremity and having low complication profile. Based on the current evidence-based literature, the requested lymphovenous bypass surgery (CPT 38999) is 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 requested lymphovenous bypass surgery (CPT 38999) is 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 reviewer 1 is board certified in vascular surgery and is actively practicing. Physician reviewer 2 is board certified in vascular surgery and is actively practicing. Physician reviewer 3 is board certified in vascular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for  Schroth Method physical therapy. The records document that this patient has a history of idiopathic scoliosis in the thoracic spine. The patients provider has recommended treatment with Schroth Method physical therapy. The aim of treatment of adolescent idiopathic scoliosis is to prevent curve progression to 50 degrees, beyond which there is a risk of continued progression in adulthood. Surgery is therefore usually recommended if the curve reaches 50 degrees during adolescence. Treatment with rigid bracing has been shown to decrease the progression of high-risk curves to the threshold for surgery  and is the most widely accepted form of treatment for the prevention of curve progression. However, a portion of patients still require surgical intervention despite treatment with bracing. There is sufficient evidence to support use of physiotherapy interventions such as the Schroth Method to increase response of the curvature to bracing. The Schroth Method consists of three-dimensional principles of correction and emphasizes postural corrections throughout the day to change habitual postures and improve alignment, pain, and progression. The Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) guidelines recommend the use of physiotherapeutic scoliosis specific exercises (PSSE) as a stand-alone therapy, add-on to bracing, and during the postoperative period. Current evidence shows Schroth exercise during bracing is superior to bracing alone in improving Cobb angles, trunk rotation, and quality of life scores. Furthermore, patients who were compliant with the Schroth program had a higher rate of Cobb angle improvement. Based on the available evidence, the requested Schroth Method physical therapy is 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 Schroth Method physical therapy is 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 reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation 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: The patient has requested reimbursement for neuropsychological testing. This patient has a long history of academic underperformance, difficulty with various executive functioning tasks, and impairments in overall organization and attention. However, there is no report of organic brain component to support neuropsychological testing following his assessment to support an indication for the neuropsychological testing performed. At present, diagnosis of ADHD and adjustment disorder can be adequately performed through psychiatric evaluation and do not require a full battery of neuropsychological testing. As noted in the medical literature, neuropsychological testing is useful to differentiate psychiatric illness from organic brain dysfunction that may be caused by dementia or traumatic brain injury. However, this patients records do not document concern for any of these organic brain components to support an indication for the testing performed. Additionally, there are no records to indicate that there was diagnostic confusion regarding the patient requiring clarification of diagnosis through this extensive testing. For these reasons, the neuropsychological testing was not medically necessary for this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided by M.D. The American College of Cardiology guidelines on the appropriate indications for myocardial strain imaging include patients prior to and following exposure to potentially cardiotoxic agents or for patients with suspected hypertrophic cardiomyopathy. In this case, the records do not reflect that the patient meets either of these indications. Therefore, myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided by M.D., was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided M.D., at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 and 3 are internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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: The patients parent has requested authorization and coverage Nutropin AQ Nuspin 20 solution pen injectable, 20 mg/2 mL. The essential criteria for human GH to treat isolated pediatric growth hormone deficiency are a height z-score two standard deviations (SDs) below the mean for age and gender as well as open epiphyses prior to initiation of GH therapy. This patients height prior to initiation of GH therapy was within normal range. Moreover, based on her bone age and height prior to GH therapy, the patients predicted adult height was within normal range. Since provocative GH tests can yield false failures for multiple reasons, such provocative tests are not the sole diagnostic criteria for isolated pediatric growth hormone deficiency. Patients with isolated pediatric growth hormone deficiency do not display predicted adult height within the normal range. Based on the available documentation, this patient does not meet the criteria for growth hormone deficiency. For these reasons, the requested Nutropin AQ Nuspin 20 solution pen injectable, 20 mg/2 mL 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 pediatrics with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trulance. Findings: In a randomized phase III clinical trial, a study reports that plecanatide (brand name Trulance) significantly improved constipation and its related symptoms with a low rate of adverse events. The American College of Gastroenterology (ACG) guidelines on the management of irritable bowel syndrome note that three studies evaluating for safety and efficacy concluded that plecanatide appeared effective for relieving overall and individual symptoms of irritable bowel syndrome, constipation-predominant. In this case, given that the patient has a diagnosis of irritable bowel syndrome with constipation and has failed multiple stimulant laxatives, osmotic laxatives, and fiber, the requested medication is medically indicated.  Therefore, Trulance is 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.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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraosseous ablation of the basivertebral nerve using the Intracept procedure. Current medical literature supports the functional benefits from the requested procedure and efficacy based on long-term clinical outcomes. Medical literature shows that patients with chronic low back pain treated with basivertebral nerve ablation sustained clinical improvements in function and pain with high responder rates at a mean of 6.4 years following treatment. Medical literature further concluded that basivertebral nerve ablation is a durable, minimally invasive treatment for vertebrogenic chronic low back pain. Therefore, the intraosseous ablation of the basivertebral nerve using the Intracept procedure is likely to be more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Intracept procedure  is 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 service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT). This patient presents with estrogen receptor (ER) positive (99%), progesterone receptor (PR) positive (100%), human epidermal growth factor receptor 2 (HER2) negative, grade I invasive ductal carcinoma. Per the American Society for Radiation Oncology (ASTRO) guidelines, this patient meets the criteria for the suitable group for the use of IORT in patients with invasive ductal cancer (Correa, et al.). Phase 3 studies have shown equivalent outcomes in patients who undergo standard radiation therapy and IORT. Therefore, this patient meets the criteria for treatment with IORT. All told, the requested IORT is 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 IORT is 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 reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Euflexxa injections (J7323) to 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 routine 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, there is a history of 60% relief from prior viscosupplementation with a series of three Euflexxa injections in 2019. The provider reported that the patient experienced relief that lasted seven months. Given this support, the requested Euflexxa injections (J7323) to the left knee 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a stress echocardiogram. Findings: The American Society of Echocardiography guidelines note that stress echocardiography is generally considered as the initial coronary disease screening test in clinical scenarios where the baseline electrocardiogram is abnormal. Stress echocardiography is the preferred test for women with an indication for noninvasive imaging for known or suspected coronary artery disease and is a reasonable option for asymptomatic adults with a strong family history and an elevated coronary calcium score. In this case, given that the records noted a family history of coronary artery disease and a coronary calcium score greater than 200, the service at issue was medically indicated. Therefore, the stress echocardiogram was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was 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 sub-specialty 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 patient has requested authorization and coverage for modafinil. Fatigue is a common symptom of patients with multiple sclerosis (MS), and may be disabling, limiting daily activity and communication, and greatly impacting quality of life. Toosy and colleagues report that management of MS symptoms may be challenging due to their interacting with each other, and that the evidence base for the management of MS symptoms with pharmacologic therapies is not strong due to the challenges of clinical trials in identifying symptomatic therapies. In a meta-analysis, Shangyan and colleagues evaluated the efficacy of modafinil versus placebo in the treatment of MS fatigue, including double-blind, randomized controlled trials. The authors concluded that modafinil was superior to placebo and was an effective pharmacologic therapy for MS fatigue. In this case, the patient has fatigue associated with MS. Given that the records note that the patients fatigue has been managed with modafinil, the requested medication is medically indicated. Therefore, modafinil is 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.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 reimbursement for laboratory gene analysis tests (CPT 81241-90) (CPT 81240-90).Findings:  The physician reviewer found that deep vein thrombosis (DVT) and pulmonary embolism may be caused by hereditary thrombophilias. It is important to know when there is an increased risk, especially in situations of pregnancy, estrogen therapy, and prolonged immobility such as surgery, long car trips, or long airplane flights, as these complications may be prevented by appropriate interventions. Connors notes that inherited thrombophilias have been reported to be associated with an increased risk of VTE in these sites, particularly thrombophilias due to the prothrombin gene mutation or factor V Leiden. In this case, the records noted a history of left lower extremity DVT. The records noted that the patient was started on Lovenos while hospitalized and later switched to Eliquis. The provider noted the possibility of lifelong anticoagulation therapy with Eliquis. In choosing between lifelong anticoagulation therapy versus discontinuing therapy, a work-up including hypercoagulability testing would assist in the decision-making process. Therefore, laboratory gene analysis tests (CPT 81241-90) (CPT 81240-90) were likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the laboratory gene analysis tests (CPT 81241-90) (CPT 81240-90) at issue were likely to have been 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 likely to have been 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 hematology 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.