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

The patient has requested authorization and coverage for Orthovisc injections (J7324) in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of lasting benefit from prior injections administered since 2012. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injections (J7324) in both knees are medically necessary for the treatment of this patient.
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 for the left knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of chronic left knee pain due to osteoarthritis. He has tried and failed other conservative measures, and the degree of osteoarthritis is not severe enough for a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, Synvisc injection  for the left knee 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

The patient has requested authorization and coverage for MRI of the left shoulder. The American College of Radiology (ACR) appropriateness criteria for the evaluation of traumatic shoulder pain notes that imaging assessment begins with conventional radiography and, depending on physical examination findings, requires MRI or magnetic resonance (MR) arthography for further assessment. In this case, the provider reported the patients clinical symptoms and examination were classic for labral tear. Conventional MRI has been shown to be up to 100% sensitive and 95% specific in the diagnosis of labral tears. Therefore, MRI of the left shoulder is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is requesting authorization for Emgality 120 mg/ml pen. Researchers found that treatment with monoclonal antibodies to calcitonin gene-related peptide (CGRP) may be indicated for patients with chronic migraines with an inability to tolerate topiramate. Research recommends clinicians and patients reassess the benefits of CGRP monoclonal antibody therapy after three to six months and continue treatment if benefits can be documented, such as a reduction in mean monthly headache days of 50% or more relative to the pretreatment baseline. The U.S. Food and Drug Administration approves the use of Emgality, a CGRP antagonist, for preventive treatment of migraine in adults. In this case, the patient had a history of chronic migraines that did not respond to topiramate. The patient reported Emgality was effective in decreasing the frequency of their migraines by 80% or more. Research found CGRP monoclonal antibody therapy is indicated and has been of documented benefit to this patient. Therefore, the Emgality 120 mg/ml pen is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan, metabolic evaluation (CPT 78608). PET can be used to aid in the diagnosis of possible encephalitis in complex clinical settings. Imaging findings demonstrate cortical lobar hyper or hypometabolism in at least one region, most commonly the parietal lobe followed by the occipital lobe. It has been shown that PET is abnormal more often than MRI during the same diagnostic period and it may be useful as an early biomarker of autoimmune encephalitis. In this case, the patient was evaluated with magnetic resonance imaging (MRI) imaging of the brain which resulted in nonspecific findings. The patients provider recommended PET imaging, which is appropriate to aid in diagnosis and treatment. Thus, the requested PET scan, metabolic evaluation (CPT 78608), is 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 requested PET scan, metabolic evaluation (CPT 78608), is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is requested authorization for Durolane injection in the left knee.Findings: Medical literature shows, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has patellofemoral pain in the left knee. The patient is trying physical therapy, with the alternative being a total knee arthroplasty. The patient has a history of relief from viscosupplementation in the right knee in 2016. Due to the similarity of the symptoms and findings of patellofemoral arthritis in the left knee, viscosupplementation injections are likely to provide relief. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Durolane injection in the left knee 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for targeted genomic sequence analysis panel (CPT 81450) provided by Neogenomics Laboratories. Based on the available documentation, this patient is suspected of having myelodysplastic syndrome (MDS). The National Comprehensive Cancer Network (NCCN) guidelines recommend that bone marrow or peripheral blood cells be assayed for MDS-associated gene mutations using gene panels. These gene mutations can establish the presence of clonal hematopoiesis, which can help exclude benign causes of cytopenias in cases with non-diagnostic morphology, but do not establish a diagnosis of MDS in the absence of clinical diagnostic criteria. The Neogenomics panel used for this patient included the recommended panel of tests per the NCCN guidelines. Given this support, the targeted genomic sequence analysis panel (CPT 81450) provided by Neogenomics Laboratories was 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 targeted genomic sequence analysis panel (CPT 81450) provided by Neogenomics Laboratories 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 reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Caris Molecular Intelligence Profile test. Desmoid tumors are perceived as a malignant condition due to the aggressive growth pattern of the fibromatosis. Patients with desmoid tumors require a multidisciplinary approach for treatment (Penel, et al.; Schmitz, et al.). The invasive pattern and the presence of mutations make the desmoid tumors most akin to soft tissue sarcomas (Trautmann, et al.). Patients with refractory or relapsed cancer that have exhausted standard treatments are generally considered for clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues reported on 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors found that the regimen selected by molecular profiling offered a 27% survival advantage. There are also reports of mutations identified by next generation sequencing that are responsive to imatinib (Trautmann, et al.). This patient has exhausted the current standard of care therapies for desmoid tumors. A clinical trial is reasonable as a targeted therapeutic approach based on molecular profiling. To help direct treatment, the Caris Molecular Intelligence Profile test 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 Caris Molecular Intelligence Profile test 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 reviewer  is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer  is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer  is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly psychology visits and somatic experience therapy. The records provided for review indicate that this patients weekly psychology sessions have consisted of cognitive behavioral therapy (CBT) processing therapy. Reports show strong evidence to support the efficacy of prolonged cognitive therapy for the treatment of patients with PTSD. Reports further state that there is a moderate strength of evidence for CBT, CBT processing therapy, narrative exposure therapy, and cognitive therapy. Regarding the frequency of visits, it is generally established that in order to be effective, psychotherapy is conducted on a weekly basis. Given this patients presentation and prior response to weekly psychotherapy, the requested weekly psychology visits are medically necessary. However, the peer-reviewed medical literature has not demonstrated somatic experience therapy to be effective for patients with PTSD. Researches conducted a study on 63 patients to evaluate somatic experiencing therapy. Researchers found that somatic experience therapy may be an effective therapy method for PTSD, but that further research is needed to understand which patients would benefit most from this treatment modality. Given these findings, the requested somatic experience therapy is not medically necessary for treatment of this patient. All told, the requested weekly psychology visits are medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for ExomeNext-Trio Plus mtDNA whole exome sequencing genetic analysis. Whole exome sequencing is appropriate and beneficial in this patients medical management. The patients diagnosis has not been established and he presents with multiple complex findings including feeding difficulties, hypoglycemia, macrocephaly, speech delay, and abnormal thyroid function studies. Whole exome sequencing can be used to identify the underlying molecular basis of a genetic disorder in this patient and will test the largest number of genes than any other genetic test using next generation sequencing technology. Multiple studies have demonstrated the utility of whole exome sequencing to identify disease-associated genetic variants across a diverse spectrum of diseases which directly affect treatment. Thus, the requested ExomeNext-Trio Plus mtDNA whole exome sequencing genetic analysis is likely to be more beneficial for evaluation  of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endocrinology services at a tertiary care facility. Research notes that uncontrolled type 2 diabetes mellitus can adversely impact small and large vessels, eventually leading to microvascular and macrovascular complications, including retinopathy, nephropathy, neuropathy, and cardiovascular disease. Research notes that early intervention is of great importance to minimize the burden of the disease and decrease the likelihood of long-term complications. Researchers demonstrated the importance of specialty care for adults with type 2 diabetes, finding that after one year of specialty care, there were significant improvements in glycemic control, blood pressure and cholesterol levels. While primary care physicians often manage type 2 diabetes, endocrinologists have more expertise with this patient population, particularly with more complicated patients and those with worse glycemic control. In this case, specialty endocrinology services would be indicated to continue management. In this clinical setting, outcomes are improved with specialty endocrinology services. Therefore, endocrinology services at a tertiary care facility are 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 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for HP Acthar Gel injections, 80 units three (3) times weekly.The medical literature does not support that the requested medication is medically necessary. The current recommendation for the treatment of sarcoidosis is corticosteroids followed by steroid sparing agents (Wijsenbeek, M., and Culver, D.; Liss, D., et al.). There are currently no national guidelines, randomized controlled trials or large cohort studies demonstrating the superiority or non-inferiority of Acthar to corticosteroids (Metersky, M.; Liss, D., et al.). In this case, the patient has end-stage lung disease from sarcoidosis with pulmonary arterial hypertension. The patient has not responded to prednisone, and more potent steroids were not recently tried due to an assumed lack of response. Current medications include Imuran, Revatio, Tracleer and Tyvaso. The current medical literature, however, does not support that Acthar is safe and effective as treatment for pulmonary sarcoidosis. Accordingly, the requested HP Acthar Gel injections, 80 units three (3) times weekly, are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for genetic testing, whole exome (CPT codes 81404, 81405, 81406, 81407, 81408, and 81479). The records provided for review indicate that this patient likely has an underlying connective tissue disorder, the most typical of which is hypermobile Ehlers-Danlos syndrome. A diagnosis of hypermobile Ehlers-Danlos syndrome is made clinically and does not require genetic testing. However, according to the providers evaluation, the patients clinical picture is multisystemic in nature. Given the potential overlap with other forms of Ehlers-Danlos syndrome, the provider recommended a connective tissue sequencing panel. The clinical implications of diagnosing subtypes of Ehlers-Danlos syndrome merit vigilant surveillance (Chu, et al.; Frank, et al.). Thus, next generation sequencing for vascular Ehlers-Danlos syndrome and related disorders (CPT 81408) is appropriate for this patient. Thus, genetic testing CPT code 81408 is 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 genetic testing CPT code 81408 is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the requested services is 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: Physician reviewer 1 is board certified in pediatrics with subspecialty certification in genetics and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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.