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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transforaminal discectomy. Transforaminal endoscopic discectomy is a percutaneous endoscopic method of discectomy. Transforaminal endoscopic discectomy is superior to open microdiscectomy in the length of the associated hospital stay. However, there are no differences in leg pain, functional recovery and incidence of complications between transforaminal endoscopic discectomy and standard open microdiscectomy. In this case, the patient has a history of low back and buttock pain that failed conservative treatment including physical therapy, chiropractic manipulation, and epidural steroid injection. Evidence of L5 radiculopathy is present and the patient had pain that interfered with activities of daily living. A provocative discography/CT scan documented concordant pain at two levels that was associated with annular tears and herniations. There was clinical and imaging evidence of two-level discogenic pain with radiculopathy, and the pain source was identified. Therefore, the decompressive surgery consisting of percutaneous transforaminal endoscopic discectomy at L4-5 and L5-S1 on the left was medically necessary. Accordingly, the transforaminal discectomy services provided to the patient were medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a transgender enrollee has requested authorization and coverage for bilateral mastectomy. The World Professional Association for Transgender Health (WPATH), a worldwide authority on transgender health issues, has stated that medically necessary gender affirming/confirming surgical procedures include bilateral mastectomy. The medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. These procedures are reconstructive surgeries, and chest surgery may be a medical necessity for someone who has had persistent gender dysphoria. The WPATH Standard of Care, version 7, clearly mentions that chest surgery in Female to Male (FTM) patients could be carried out earlier than the age of majority. A recent study of adolescents and young adults showed significant improvement of chest dysphoria in transmasculine youth below the age of 18 years old. The denial of chest masculinization surgery, based only on the age of legal majority, is clinically inappropriate and against current available data and guidelines. In this case, the patient has a persistent and documented diagnosis of gender dysphoria that includes chest dysphoria. The patient has female size breasts, which are resulting in social and personal distress for him. Under these circumstances, the requested bilateral mastectomy is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent 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: A female enrollee has requested reimbursement for the gene testing. The Guardant360 assay is a cell free DNA assay performed on an individual patients plasma. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the Guardant360 assay adds to decision making ability, or yields a result that is clinically beneficial. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the gene testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the gene testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Urine PCR test in order to evaluate for Lyme disease and co-infections. This patient is at low risk for active Lyme disease. Prior evaluation has included multiple negative Lyme tests. As noted in the medical literature, the accepted Lyme testing strategy includes antibody and Western blot analysis. The current data does not support an indication for Urine PCR testing in this clinical setting. For those reasons, the requested Urine PCR test is not medically necessary for evaluation and management of the patients medical condition.Final Result: The reviewer determined that the requested services are 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 internal medicine with subspecialty certification in infectious 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

The parent of an enrollee has requested authorization and coverage for the medication Uceris 9 mg. Budesonide MMX (Uceris) is a steroid formulation which has much lower systemic absorption than prednisone, and concomitantly fewer side effects. Prolonged systemic exposure to steroids is particularly problematic in the pediatric age group, as they suppress linear growth and prevent achievement of maximal bone density. For that reason, in a child who is unable to taper off of prednisone, budesonide MMX is an appropriate alternative. According to the guidelines of the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), budesonide MMX is the appropriate treatment in the setting of colitis (with left sided disease) when there has been an incomplete response to mesalamine at maximum dose. The ESPGHAN paper also points out that most children with mild to moderate ulcerative colitis will not achieve remission with mesalamine monotherapy alone. In this case, the patient has had incomplete response to mesalamine at maximal dose, and has been unable to discontinue prednisone. Furthermore, a sequential trial of salicylates, such as a trial of balsalazide in place of mesalamine is not indicated in the pediatric age group. For these reasons, initiation of budesonide MMX for induction of remission with minimization of steroid side effects is appropriate. Accordingly, Uceris 9 mg is medically necessary for treatment of the patients medical condition.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 pediatrics, with subspecialty certification in pediatric 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parents of a patient has requested authorization and coverage for immunotherapy/allergy shots, one a week for 52 weeks (two sets). Findings:  The physician reviewer found that candidates for immunotherapy are patients whose symptoms are not controlled adequately by medications and avoidance measures or those experiencing unacceptable adverse effects of medications. The selection of allergens for immunotherapy is based on clinical history, the presence of specific immunoglobulin E (IgE) antibodies, and allergen exposure. According to the American Academy of Allergy, Asthma and Immunology (ACAAI), allergen immunotherapy extracts should be prepared individually for each patient. Individualized patient extracts allow for customized treatment specific to the patients identified allergen sensitivities and reduce the risk of allergen cross-contamination. Additionally, the provider must specify the starting immunotherapy dose, the target maintenance dose, and the immunotherapy schedule. The immunotherapy build-up schedule entails administration of gradually increasing doses during a period of approximately 28 weeks. After a patient completes the build-up dose, the patient enters the maintenance dose. This patients clinical documentation includes evidence of skin testing showing findings correlated with seasonal and perennial allergic rhinitis. All told, the requested immunotherapy/allergy shots, one a week for 52 weeks (two sets), are supported as medically necessary for treatment of this patients allergic rhinitis.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 internal medicine with subspecialty certification in allergy and immunology 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 the WalkAide functional electrical stimulation device.Findings:  Three physician reviewers found The WalkAide device is a compensatory orthosis that triggers ankle dorsiflexion using peripheral neural pathways to mitigate foot drop during swing phase. The same result, however, is accomplished using a conventional passive ankle foot orthosis (AFO), such as a molded thermoplastic AFO.  In 2013, studies showed equivalent functional gains from using the WalkAide device versus conventional AFOs. Studies concluded that no statistically significant between-group differences were found for primary or secondary endpoints between the functional electrical stimulation-aided orthosis (WalkAide) and conventional AFO groups.  There is a lack of high-grade evidence supporting that the use of the type of device in question effectuates sustained, significant strength or functional benefits (i.e., while the orthosis is not being worn) in the setting of any neurological condition resulting in foot drop, including multiple sclerosis. The currently available literature does not demonstrate a marginal benefit of functional electrical stimulation devices, such as a WalkAide, over conventional AFOs in the setting of neurologically-based foot drop, such as the patients multiple sclerosis-related foot drop. While some risks related to pressure injury at contact points using a conventional thermoplastic AFO may be mitigated by a functional electrical stimulator-aided AFO, this risk mitigation does not come without other biomechanical costs and risks. There are, for instance, risks of decreased mediolateral stability with potentially increased instability during standing and the stance phase of gait, as well as issues related to the reliability and ease of use of the devices  and sustained electrode adherence/and or conductivity through the course of a day. This type of device may not be appropriate in the setting of lower limb weakness and spasticity that extends more proximally than the foot and ankle, such as that which occurs in the setting of multiple sclerosis. No net health or functional benefit of the requested device would be expected over a properly fitted conventional ankle foot orthosis for the patients condition. Thus, the requested WalkAide functional electrical stimulation device is not likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested device 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: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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 Orthovisc injections. Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. In a systematic review of meta-analyses, Campbell and colleagues conducted a systematic review of overlapping meta-analyses comparing hyaluronic acid injections with other non-operative treatment modalities for knee osteoarthritis. The authors found that intraarticular hyaluronic acid improves knee pain and function for up to 26 weeks. In addition, Maheu and colleagues noted that the benefits of intraarticular hyaluronic acid on knee osteoarthritis may include mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) andthe re-establishment of joint homeostasis through induction of endogenous HA [hyaluronic acid] production, which continues long after the exogenous injection has left the joint. Moreover, hyaluronic acid injections have been shown to have a good safety profile. This patient reported consistent relief with hyaluronic acid injections. Given this support, the requested Orthovisc injections are medically necessary for treatment of this patients knee osteoarthritis. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for palatopharyngoplasty with a partial glossectomy. The records provided for review document that this patient has been unable to tolerate treatment with CPAP. As noted by the provider, due to the patients upper airway obstruction, treatment with CPAP requires a high level of pressure. This high pressure results in abdominal symptoms from swallowed air. Additional treatment with a mandibular advancement device worsened the patients TMJ symptoms. Physical examination revealed a retroplaced tongue consistent with Mallampati 3. Given the failure to improve with CPAP and an oral device, palatopharyngoplasty and partial glossectomy are reasonable treatment options given this patients anatomy. Thus, the requested palatopharyngoplasty with a partial glossectomy are supported as medically necessary for treatment of this patients OSA. 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 otolaryngology 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: A 64-year-old male enrollee has requested authorization and coverage for the transoral incisionless fundoplication (TIF) procedure utilizing the EsophyX device (CPT code 43210). The efficacy of TIF has been studied in randomized controlled trials (Sami Trad). However, the conclusions are contradictory (Witteman, et al). The 2013 American College of Gastroenterology (ACG) guidelines for treatment of GERD report that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy (Katz, et al). Auyang and colleagues found that further studies are required to define optimal techniques and most appropriate patient selection criteria, and to further evaluate device and technique safety. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) do not recommend endoscopic procedures for patients with complicated GERD which the guideline defines as dysphagia or Barretts esophagus and report that the long-term follow-up data for TIF are limited. Thus, the requested TIF procedure utilizing the EsophyX device (CPT code 43210) is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested TIF procedure utilizing the EsophyX device (CPT code 43210) is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested TIF procedure utilizing the EsophyX device (CPT code 43210) is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the fetal chromosomal aneuploidy (CPT 81420) genetic testing. The American College of Obstetricians and Gynecologists (ACOG) has issued a practice bulletin regarding non-invasive prenatal testing. The ACOG bulletin noted that cell-free DNA screening evaluates short segments of DNA in maternal blood and can be used to screen for a variety of fetal conditions. The ACOG promotes aneuploidy screening or diagnostic testing for fetal genetic disorders, regardless of maternal age. The patient in this case underwent testing while pregnant consistent with the ACOG recommendations. Given this support, the fetal chromosomal aneuploidy (CPT 81420) genetic testing was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three physician reviewers found the fetal chromosomal aneuploidy (CPT 81420) genetic testing was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the fetal chromosomal aneuploidy (CPT 81420) genetic testing was likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in obstetrics and gynecology and are actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology with subspecialty certification in maternal and fetal 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.