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 Medtronic bladder control therapy. After behavioral and pharmacologic therapy, the third-line of therapy is PTNS or Botox injection and subsequently InterStim insertion. The American Urologic Association (AUA) treatment guidelines and current literature support a role for this treatment. However, the medical literature does not support PTNS as an ongoing maintenance therapy. Thus, PTNS weekly sessions for 12 weeks is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while maintenance therapy with PTNS is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested PTNS is not 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 a portion of 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 partially overturned.Credentials/Qualifications:  One reviewer is board certified in urology and is actively practicing. One reviewer is board certified in urology and is actively practicing.  One reviewer is board certified in urology 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 Afrezza inhalation powder. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients type I diabetes mellitus with hyperglycemia. The submitted documentation does not support the medical necessity of the requested medication. Fala and colleagues, state that Afrezza, (insulin human) inhalation powder is a rapid-acting technosphere insulin administered via a breath-powered oral inhaler to patients with diabetes requiring prandial insulin. Although it achieved the pre-specified non-inferiority margin of 0.4 percent, as compared to injections of rapid acting insulin in a recent trial, patients with type 1 diabetes, who received Afrezza, demonstrated less reduction in hemoglobin A1c levels. All told, while there is some evidence supporting the use of Afrezza insulin, it is not sufficient to support the need for this medication in this patient rather than injectable insulin. Therefore, Afrezza inhalation powder 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 internal medicine with sub-specialty 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: An enrollee has requested authorization and coverage for Synvisc-One (hyaluronan) injection. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient presents with chronic right knee pain with associated popping, locking, and giving way. Functional limitations are noted in activities of daily living. Clinical examination findings are consistent with radiographic evidence of bicompartmental osteoarthritis, worse in the medial compartment. He is status post left total knee replacement with postoperative blood clots requiring hospitalization. He is indicated for right total knee replacement but wants to delay this due to his deep vein thrombosis/pulmonary emboli risk factors. Literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given the previous response and to assist in delaying total knee replacement, a repeat Synvisc-One injection is indicated. Therefore, Synvisc-One (hyaluronan) injection is medically necessary for the 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: A 59-year-old male enrollee has requested authorization and coverage for computed tomography (CT) and magnetic resonance imaging (MRI) services to be provided every four (4) months for the next five (5) years. The patients tumor size of 17 cm places it in a high risk category. Even though resection was complete and the first post-operative scans revealed no evidence of local or distant metastasis, careful surveillance is indicated. The National Comprehensive Cancer Network (NCCN) guidelines for this stage of renal cell cancer advocate CT of the chest every six months for three years, then annually for five years. MRI of the chest is not indicated as such technique does not evaluate the lungs for metastatic deposits. The NCCN guidelines advocate surveillance for a similar time frame using MRI in the abdomen and pelvis. For these reasons, CT of the chest and MRI of the abdomen every six months for three years after the initial post-operative CT scan, and then annually for five years, are supported as medically necessary.Final Result: The reviewer determined that a portion of the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Butrans, nerve ablation, guided steroid injections in coccyx and both sides of sacroiliac joint, spinal cord stimulator, and pain pump. The submitted documentation fails to demonstrate the medical necessity of the requested medication, services and devices. The current medical evidence does not support chronic opiate maintenance for non-malignant pain. This patient does not meet the clinical practice guidelines for any of the interventional procedures requested. The medical evidence does not support these modalities in this clinical setting. Therefore, the requested coverage for Butrans, nerve ablation, guided steroid injections in coccyx and both sides of sacroiliac joint, spinal cord stimulator, and pain pump are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication, services and devices are 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 sub-specialty 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing for evaluation of the enrollees melanoma. Findings:  The physician reviewer found that staging system spelled out by Balch. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or class 2 based on the risk of metastasis. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear whether the DecisionDx-Melanoma can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing was not likely to have been more efficacious than other methods of evaluating this patient. 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 reimbursement for the second CPT code 64636. Findings:  Three physician reviewers found that the submitted records do not document an official pain diary for the medial branch block done prior to the requested radiofrequency ablation. Prior to radiofrequency ablation, the literature recommends using a pain diary for the day to verify when the local anesthetic wore off and not using anything other than a local anesthetic for the test. Moreover, it is possible the patient would have obtained the same relief from a steroid injection alone without also having the increased risk from the radiofrequency ablation. No mention of prior failure from facet injections is done. Also, no mention of a home exercise program is discussed. Finally, the records do not document an examination consistent with facet arthropathy at the requested levels. Thus, the second CPT code 64636 was not likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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 reimbursement for laboratory testing (CPT codes 82172, 83704, 83685 and 83698) Findings:  Three physician reviewers found 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 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), 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 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, laboratory testing (CPT codes 82172, 83704, 83685 and 83698) provided on 2/16/18 was not likely to have been of greater benefit 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Humira. There is sufficient support for the requested medication in this patients case. Granuloma annulare (GA) is a non-infectious condition characterized by annular papules. Generalized GA can be disfiguring because of the extensive dissemination of the lesions. Generalized GA may lead to scarring most pronounced on sun-exposed areas. Recently, tumor necrosis factor (TNF)-alpha inhibitors have been reported to improve GA. Humira (adalimumab) is an alternative agent that binds to membrane-bound and soluble TNF-alpha, showing great promise in treating recalcitrant, generalized GA. The medical evidence indicates that Humira may be an effective and well-tolerated treatment for GA. It may be particular benefit for patients who have generalized or disseminated GA. Therefore, Humira 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the advanced lipoprotein testing. The American College of Cardiology Foundation (ACCF) guidelines do not support use of the advanced lipid testing. Rather, the ACCF guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. The guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. These guidelines are formulated based on thorough review of current literature, and are vetted in a group of cardiology experts before publication. Therefore, the advanced lipoprotein testing was not 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 testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: An enrollee has requested authorization and coverage for upper eyelid blepharoplasty. The criteria for upper blepharoplasty are not met in this case. The patients visual field deficit does not extend to within 30 degrees of fixation. In addition, there is no documentation of more than 30 degrees of improvement in the visual field with the eyelids taped up compared to primary gaze. Furthermore, the photographs show an upper eyelid margin pupillary light reflex distance (MRD-1) of about 4-4.5 mm. This indicates a completely unobstructed visual axis. Although the patients condition constitutes an abnormal structure of the body, the requested surgery will not improve function based on the eyelid taping results, and will not provide a more than minimal improvement in the patients appearance. Thus, the requested upper eyelid blepharoplasty is not medically necessary and not reconstructive in nature. Final Result: The reviewer determined that the requested services are 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 ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for continuous positive airway pressure (CPAP) supplies and water chamber for humidifier used with positive airway. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the equipment at issue. In this case, the patient had a diagnosis of obstructive sleep apnea for which she was prescribed positive airway pressure therapy. She was noted to be compliant with her use of positive airway pressure therapy. It is well-established that positive airway pressure supplies should be replenished on a periodic basis. This is in part to maximize patient therapy with the devices. In this case, the replacement supplies that were furnished to the patient were medically appropriate and standard of care.  Therefore, continuous positive airway pressure (CPAP) supplies and water chamber for humidifier used with positive airway were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was 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 with sub-specialty certification in sleep 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: An enrollee has requested authorization and coverage for Stelara. Psoriasis is a chronic inflammatory skin disease which typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. About 20% of patients suffer from severe psoriasis, necessitating systemic drugs such as acitretin, methotrexate, cyclosporin A or the newer biologic agents. Up to 30% of psoriatic patients develop psoriatic arthritis (also known as psoriatic arthropathy), a type of inflammatory arthritis. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Ustekinumab (Stelara) is a human monoclonal antibody that binds to the p40 subunit common to both interleukin (IL)-12 and IL-23. It is indicated for use in adult patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. The patient has symptoms of plaque psoriasis and psoriatic arthritis that require systemic treatment. Phototherapy is generally not effective for joint inflammation. These factors, as well as the excellent safety and efficacy profiles of Stelara, support the use of the requested medication in this clinical setting. As such, the requested Stelara 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 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.