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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for multilevel lumbar fusion from L3-S1. Findings:  The physician reviewer found that in the medical literature, a study recommended surgery for spinal stenosis for patients who do not improve with conservative treatment. Another study found that flatback syndrome can be a significant source of disability, affecting stance and gait, and resulting in significant pain. The authors reported that despite significant complication rates, surgical management to recreate lumbar lordosis using interbody fusions and/or osteotomies can significantly improve quality of life. This patient presented with persistent and worsening severe low back pain radiating into the bilateral lower extremities with weakness on the right side. Functional limitations are noted in activities of daily living. Signs/symptoms are consistent with neurogenic claudication. Clinical exam findings have documented motor deficit and sagittal imbalance consistent with imaging evidence of a rotational scoliosis centered at L3, dynamic spondylolisthesis at L4-5, moderate spinal stenosis at L3-4, and severe facet arthropathy at L3-4, L4-5 and L5-S1. She has severe spondylolisthesis at L4-5, spinal deformity at L3-4, flatback syndrome, and stenosis at L5-S1. Detailed evidence of a recent and comprehensive non-operative treatment protocol trial and failure has been provided for review. There is radiographic evidence of spondylolisthesis with spinal segmental instability on flexion and extension x-rays. The patients condition supports the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. For these reasons, the requested multilevel lumbar fusion from L3-S1 is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested multilevel lumbar fusion from L3-S1 is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing.Findings:  Two of the three physician reviewers found that guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.   Although the results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Thus, advanced lipoprotein testing was not likely to have been more effective than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 dopamine transporter (DaT) single photon emission computed tomography (SPECT) scan.Findings:  Two of the three physician reviewers found while a DaT SPECT scan is not indicated for all patients with features of clinical Parkinsonism, it has been shown to be useful in cases where the diagnosis of idiopathic Parkinsons disease versus essential tremor is being considered. In this patients case, the exact diagnosis is not clear. It is imperative to provide a definitive diagnosis, as treatment for Parkinsons disease versus essential tremor is quite different, and placing the patient on an extended trial of dopamine therapy would place the patient at risk of significant side effects. In this case, the requested services may aid in the management of this patient. In sum, the requested DaT SPECT scan is likely to be more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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 neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for prolotherapy. Nationally recognized evidence-based medical guidelines do not support prolotherapy for treatment of back pain. A systematic review concluded that there is a lack of evidence demonstrating equivalent or superior efficacy for prolotherapy injections for chronic low back pain when compared to standard available therapies. There is conflicting evidence regarding the efficacy of prolotherapy injections for patients with chronic low back pain. This patient presents with a history of progressively worsening low back pain radiating into her legs to her feet. Clinical examination findings document sensory deficit consistent with imaging evidence of L3-5 degenerative disc disease with L5 nerve root abutment corroborated by electrodiagnostic evidence of L5 radiculopathy. She has failed to adequately respond to long-term comprehensive non-operative treatment. However, current evidence-based medical guidelines and peer-reviewed literature do not support the use of prolotherapy in the low back pain due to conflicting studies concerning the effectiveness of prolotherapy. Therefore, the requested prolotherapy is not likely to be more beneficial for treatment of the patients medical condition that any available standard therapy.One reviewer found that prolotherapy is likely to be more beneficial for treatment of the patients medical condition that any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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: A patient has requested authorization and coverage for enrollment into the bariatric Options Program. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees morbid obesity and osteoarthritis of both knees. At issue in this case is whether the requested enrollment into a bariatric Options Program is medically necessary for treatment of the enrollees medical condition.Findings:  The physician reviewer found that in order to justify participation in a bariatric program in general, one must show that they are consistently working and successfully implementing long-term dietary changes conducive to weight loss.  Post-bariatric program and surgery results strongly depend on these habits. Factors that place patients into a high-risk category for venous thromboembolism (VTE) after bariatric surgery may include high body mass index, advanced age, immobility, prior VTE, known hypercoagulable condition. Additional factors are obesity hypoventilation syndrome, pulmonary hypertension, venous stasis disease, hormonal therapy, expected long operative time or open approach, and male gender.The patient demonstrates the inability or significant difficulty ambulating (poor functional status) and having a BMI of greater than 50 kg/m2. These are risk factors that increase risk of post-surgical deep vein thrombosis and/or venous thromboembolism. Additionally, the patient has not demonstrated the ability to consistently work and successfully implement long-term dietary changes conducive to weight loss. These factors in addition to the inability to meet the program requirements to walk for 15 minutes without stopping do not support the medical necessity of the bariatric program. Therefore, the bariatric Options Program is not medically necessary.Final Result: The reviewer determined that the requested service 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 family 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX Reflux Management System (CPT 43284). Findings:  The physician reviewer found that here is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX Reflux Management System is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX Reflux Management System can be recommended. Additionally, LINX Reflux Management System has been associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not demonstrate that LINX Reflux Management System is more likely to be beneficial in this case than standard treatment, surgical fundoplication. Thus, LINX Reflux Management System (CPT 43284) is not likely to be of greater benefit than other treatment options. Final Result: Two of the three physician reviewers found  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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for automated whole breast ultrasound. A peer-reviewed medical literature states that automated whole breast ultrasound is US Food and Drug Administration (FDA) approved for use in screening for breast cancer as an adjunct to mammography. Consistent with this recommendation, the bulk of available data favoring a clinical role for automated whole breast ultrasound supports its use with mammography, not as a replacement for mammography. This is due to the limitation on automated whole breast ultrasound in the detection of microcalcifications and evaluating the deeper portions of the breast. This patient underwent evaluation with an automated whole breast ultrasound in 2017 which did not detect any abnormality other than dense breasts. The providers recommendation at that time was to consider tomosynthesis as a supplemental study to screen for breast cancer in this patient with dense breasts. In conclusion, automated whole breast sonography is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that automated whole breast sonography is 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 requested service is 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 diagnostic radiology and is actively practicing. One Reviewer is board certified in diagnostic radiology and is actively practicing.  One Reviewer is board certified in diagnostic radiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for prolotherapy. Nationally recognized evidence-based medical guidelines do not support prolotherapy for treatment of back pain. A systematic review and concluded that there is a lack of evidence demonstrating equivalent or superior efficacy for prolotherapy injections for chronic low back pain when compared to standard available therapies. The authors concluded that there is conflicting evidence regarding the efficacy of prolotherapy injections for patients with chronic low back pain. This patient presents with a history of progressively worsening low back pain radiating into her legs to her feet. Clinical examination findings document sensory deficit consistent with imaging evidence of L3-5 degenerative disc disease with L5 nerve root abutment corroborated by electrodiagnostic evidence of L5 radiculopathy. She has failed to adequately respond to long-term comprehensive non-operative treatment. However, current evidence-based medical guidelines and peer-reviewed literature do not support the use of prolotherapy in the low back pain due to conflicting studies concerning the effectiveness of prolotherapy. Therefore, the requested prolotherapy is not likely to be more beneficial for treatment of the patients medical condition that any available standard therapy.One reviewer found that prolotherapy is likely to be more beneficial for treatment of the patients medical condition that any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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: A male enrollee has requested reimbursement for residential psychiatric care. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.At issue in this case is whether the residential psychiatric care for the dates 11/14/17 to 12/5/17 was medically necessary for treatment of the enrollees behavioral health condition.The preferred level of care is the least intensive level that meets treatment objectives while providing safety and security for the patient. There were no significant post-acute withdrawal symptoms. The patient was not a danger to himself or others. He did not show significant emotional, behavioral, cognitive or impulsive symptoms to support residential level of care. The patient was able to perform activities of daily living independently. The patient was motivated and appeared to be working the program. There was no evidence of a high degree of impulsivity, aggression, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. The patient was stable medically and psychiatrically. He was beginning to show insight into his behavior, learning to identify triggers, was working on his inventory, and was in the contemplative stage. No new problems had arisen and there was no evidence to indicate that returning him to his environment would lead to destabilization. Although the patient continued to struggle with his emotions and required further treatment to help develop coping skills, this did not require the structured environment of a residential setting. The patient could have been stepped down to an ambulatory level of care, with consideration for medication assisted treatment. The patient could continue recovery in the ambulatory level of care in conjunction with a 12-step program. Relapse risk in and of itself is not a reason to keep a patient in the residential treatment setting. Therefore, the requested residential psychiatric services were not medically necessary. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an eNeura sTMS mini migraine device. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees migraine headaches.At issue in this case is whether the requested eNeura sTMS (synchronized transcranial migraine stimulation) mini migraine device is medically necessary for treatment of the patients medical condition.Findings:  The physician reviewer found that a study noted that sTMS was assigned to subjects and revealed a reduction of headache days from baseline (9.06 days). This study suggests that sTMS may be an effective, well-tolerated treatment option for migraine prevention. The study noted early treatment of migraines with aura by sTMS resulted in increased freedom from pain at two hours compared with sham stimulation; and absence of pain was sustained at 24 hours and 48 hours after treatment. Synchronized transcranial migraine stimulation could be a promising acute treatment for some patients that have migraines with aura.Synchronized transcranial migraine stimulation has shown benefit for migraine headache treatment when used in a controlled fashion by providers. The device has not been studied in controlled fashion for home use application. As such, the eNeura sTMS mini migraine device is not medically necessary. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in pain 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.