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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) (CPT 78815) with computed tomography (CT) for attenuation scans. Renal cell carcinoma most commonly metastasizes to the lungs, bone, liver, and brain. Metastatic bone lesions from renal cell carcinoma are typically lytic in nature. Bone scintigraphy has limited sensitivity in diagnosing lytic bony metastases in comparison to PET/CT, which has higher sensitivity and accuracy. In the peer-reviewed medical literature, it is noted that the utility of PET/CT is limited for renal cell carcinoma. However, the authors found that PET/CT has a specialized role for the prediction of the degree of tumor differentiation and allows for prognosis of the disease. The authors concluded that PET/CT has higher sensitivity and accuracy when compared with bone scan to detect renal cell carcinoma metastasis to the bone. Monitoring patients in this clinical setting with osseous metastases with PET/CT can therefore change management based on these results. In this case, the patients provider specifically stated that the PET/CT studies were performed to help guide treatment decisions. Given this support, the PET (CPT 78815) with CT for attenuation scans were 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 PET (CPT 78815) with CT for attenuation scans were 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 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: Physician reviewers 1, 2, and 3 are board certified in diagnostic radiology 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 DecisionDx-Melanoma Gene Assay. For cutaneous melanoma stage I-II measuring 0.3 mm, the DecisionDx-Melanoma Gene Assay has been validated as an accurate predictor of five-year metastatic risk. Treatment plans for cutaneous melanoma, including possible adjuvant therapy use, are based upon the individual patients risk of recurrence. The alternative testing for recurrence risk and treatment decision-making is a sentinel lymph node biopsy (SLNB). Low-risk results from the DecisionDx-Melanoma Gene Assay identifies patients who could avoid invasive SLNB. In this case, cutaneous metastases would be difficult to detect from full-body skin screening examination surveillance due to the absence of pigmentation in the tumor. Surveillance with full-body positron emission tomography (PET) scan would involve additional exposure to radiation. The patients tumor is amelanotic melanoma measuring 0.55 mm. In this scenario, the results of the DecisionDx-Melanoma Gene Assay were associated with a low risk of recurrence within five years. This result was likely to spare the patient from undergoing SLNB. For these reasons, the DecisionDx-Melanoma Gene Assay was 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 Gene Assay was 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 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: 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gammagard IVIG treatment.Medical literature does not support that the requested medication is medically necessary. The optimal therapy of postural tachycardia syndrome (POTS) is not clear and likely varies depending on individual symptoms. The Heart Rhythm Society Expert Consensus Statement on the treatment of POTS states that few treatments have been tested with the usual rigor of randomized clinical trials, and there is no consensus as to whether specific treatments should be targeted to subsets of POTS or whether a uniform approach should be used. Standard therapy for treatment of patients with POTS include exercise training, lower extremity compression, volume expanders (liberalization of salt intake, florinef), beta-blockers and vasoconstrictors (midodrine). Other therapies remain under investigation, and evidence of benefit is needed before they can be recommended. The Heart Rhythm Society Expert Consensus Statement on the treatment of POTS does not include IVIG among its recommended treatments for POTS. Vernino and Stiles state that the published literature is limited to a small number of case reports noting improvement in POTS symptoms after intravenous immunoglobulin. In this case, the patient has a diagnosis of postural tachycardia syndrome (POTS) and her provider has recommended intravenous immunoglobulin (IVIG) therapy. The expert consensus statement on the treatment of POTS does not include IVIG among the recommended treatments, however, and there is insufficient evidence for its use under these circumstances at this time. Accordingly, Gammagard IVIG treatment is not medically necessary to treat the patients medical condition.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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Depo-Testosterone.The submitted documentation supports that the requested medication is medically necessary. Low testosterone can lead to such complications as reduced libido, erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis, low bone mass, depressed mood and fatigue. For these reasons, many physicians treat patients with hypogonadism when their testosterone level is less than 350 ng/dl. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. In this case, the patient has been taking growth hormone under the care of an endocrinologist, and lab testing has shown that he has total testosterone that is at the low end of the general target level, and free testosterone that is below the reference range for adult males. Under these circumstances, the requested Depo-Testosterone is medically necessary for treatment of the patients condition.Final Result: The reviewer determined that the requested medication is medically necessary for the 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 endocrinology, diabetes and metabolism, 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 percutaneous implantation of a dorsal root ganglion (DRG) stimulator into the lumbar spine. Authors concluded that there is adequate is randomized clinical trial evidence that a DRG placement provides superior pain relief to spinal cord stimulation for complex regional pain syndrome (CRPS) and causalgia of the lower limb. Researchers concluded that DRG is an effective treatment for a variety of neuropathic pain syndromes, in addition to CRPS. Other studies concluded that DRG might be an effective long-term method of treating discrete, localized areas of chronic neuropathic pain. This patient presents with a history of chronic low back and left leg pain refractory to comprehensive conservative treatment. Her pain is rated as 7-8/10 with severe limitations in activities of daily living. Clinical examination findings have documented no focal neurologic deficits, and there is no imaging or electrodiagnostic evidence of nerve root compression. She has been diagnosed with left lower extremity causalgia. She has obtained psychological clearance for the use of a spinal cord stimulator. She underwent a trial of DRG stimulation with documented 100% pain relief, improvement in her ability to perform activities of daily living, and reduction in medication use. Current evidence based medical literature supports the use of DRG stimulation for the treatment of chronic focal neuropathic pain consistent with this patients left lower extremity causalgia. All told, percutaneous implantation of a DRG stimulator into the lumbar spine is 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 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 been diagnosed with alopecia areata universalis. The provider noted that the patient had a history of alopecia areata totalis, which progressed to alopecia areata universalis. Physical examination findings included sparse inferior eyelashes on one-third of the outer corner of the patients left eye. The patient has been treated with Anthralin cream, Rogaine foam, and intralesional eyebrow injections. The patient has requested authorization and coverage for bimatoprost 0.03% eyelash solution. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether bimatoprost 0.03% eyelash solution is medically necessary for the treatment of the patients medical condition. Reasearchers reported, Eyelash and eyebrow hypotrichosis is a common sign of alopecia areata (AA) totalis or universalis. This may cause decreased protection to the eyes and be cosmetically detrimental for patients. The authors noted, In December 2008, the U.S. Food and Drug Administration (FDA) approved 0.03% bimatoprost solution (Latisse)for increasing eyelash length, thickness and darkness in patients with hypotrichosis of the eyelashes, or persons who desire lengthy eyelashes. The authors concluded, We observed an acceptable response in 43.24% of patients with bilateral eyelashes AA using 0.03% bimatoprost ophthalmic solution. The medical evidence supports the requested medication in this clinical setting. Therefore, bimatoprost 0.03% eyelash solution 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 dermatology 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 a power wheelchair, Group 3 Standard, multiple power option, sling/solid seat/back, patient weight capacity up to 300 pounds (CPT K0861); wheelchair component or accessory (CPT code K0108); power wheelchair accessory, Group 34 sealed lead acid battery (CPT E2359). The Health Plan has approved the patient for a basic group 3 powered wheelchair with occupied transit mounts and rehabilitation seating. The patient is noted to have good trunk control and is able to weight shift when needed. The requested wheelchair with tilt in space, powered elevating leg rests or custom seating would exceed the patients medical needs and are not necessary for this condition per the submitted documentation. All told, the requested power wheelchair, Group 3 Standard, multiple power option, sling/solid seat/back, patient weight capacity up to 300 pounds (CPT K0861); wheelchair component or accessory (CPT code K0108); power wheelchair accessory, Group 34 sealed lead acid battery (CPT E2359) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc injection 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 standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this patients case, the options are limited. The patient has tried and failed other conservative treatments including non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections, with the alternative being a total knee arthroplasty. All told, the requested Synvisc injection to the left knee is 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care (MAC) services (CPT 00811). The American Society for Gastrointestinal Endoscopy (ASGE) guidelines noted that, the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The ASGE states that sedation and anesthesia in gastrointestinal endoscopy can be performed with moderate sedation by the endoscopist. In this case, the patient underwent a colonoscopy for investigation of rectal bleeding. The records provided for review did not document any cardiac or pulmonary disease. There is no documentation of a history of substance abuse or of any prior history of difficulty with sedation or anesthesia. The provider assessed the patient with an ASA score of 2, which indicates a low likelihood of complications from anesthesia during the procedure. There is no indication that the patient had any risk factors making his airway difficult to manage. Based upon the medical records available for review and the most recent guidelines regarding sedation for gastrointestinal endoscopy procedures, MAC services (CPT 00811) were 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 anesthesiology with subspecialty certification in pain management 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 reimbursement for residential treatment center (RTC) services.  The American Society of Addiction Medicine (ASAM) criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. According to the ASAM guidelines for treatment, a patient should be placed in a 3.7 medically monitored intensive inpatient withdrawal management when signs and symptoms are sufficiently severe to required 24-hour inpatient care, and remain until withdrawal signs and symptoms are sufficiently resolved that he can be safely managed at a less intensive level of care. In this case, the patient did not reach moderate to severe withdrawal status. The patient required treatment for withdrawal management, consistent with dimension 1. However, the records document that his withdrawal symptoms had resolved, without medical or psychiatric complications. The patient did not meet the criteria for dimension 2 given the lack of a biomedical condition or continued drug use placing the patient at significant risk to his physical health. In addition, the patient did not meet dimension 3, as there was no documentation of an unstable psychiatric condition interfering with his abstinence, recovery, or stability. For dimension 4, the patient remained in the contemplative state of change and his provider recommended continued outpatient treatment with AA services. For dimension 5, the patient remained at risk for relapse given his lengthy history of substance use and difficulty in maintaining sobriety. The patients recovery environment was noted to include his wife, who has been negatively affected by his substance abuse. Given these findings, the patient does not meet all of the required dimensions for RTC level of care services. Accordingly, the RTC services were not medically necessary for treatment of 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 with expertise in addiction 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) services. Per the recommendations of the Clinical TMS Society, TMS therapy can be reintroduced in patients who are relapsing into depression after initially responding to TMS treatment. A sham controlled study of four weeks of TMS with an additional 18 weeks of maintenance TMS showed benefit, specifically in patients who had some benefit in the initial four weeks. The authors reported on a subset of patients who required a much longer treatment course than the six weeks with six tapering treatments to reach remission. McDonald and colleagues found that some patients required up to nine weeks of TMS to achieve response. This patient showed benefit from TMS multiple times. She therefore meets the criterion specified in these recommendations to reintroduce TMS as a full course of therapy. However, she has experienced partial benefit over the most recent course of TMS and remains in a major depressive episode. Given this finding, she may be a slow responder and may require more treatment sessions. Accordingly, the TMS services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 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.