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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for nitric oxide expired gas determination. The enrollee has asthma. She has been on Albuterol, Advair, and Combivent. She was evaluated by her pulmonologist due to complaints of a dry cough and shortness of breath with exertion. She has a history of vocal cord polyps and hoarseness, secondary to increased coughing. Her pulmonologist reported scattered bilateral expiratory wheezing. He performed pulmonary function testing and fractional exertion of nitric oxide testing. The enrollees pulmonologist reports the nitric oxide was used to assess eosinophilic airway inflammation and reports the enrollee does not need allergy reevaluation. This enrollee has a history of moderate, persistent asthma in the setting of severe rheumatoid arthritis. Exhaled nitric oxide measurement is helpful in determining whether there is inflammatory airway disease which is being caused by eosinophils. This type of asthma has specific biologic agents which are approved for use in such cases. The measurement of exhaled nitric oxide in this enrollee was appropriate to individualize and optimize her treatment. Professional societies support the use of nitric oxide measurement in selected individuals to help guide therapy.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in pulmonary diseases and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for MRI scans of the bones of the eye, face, and neck, before and after contrast. The enrollee has cardiovascular symptoms, which are being attributed to an infectious disease process. She has undergone an echocardiogram, stress test, and carotid Doppler. A computed tomography scan of the head and a magnetic resonance imaging scan of the brain were normal. Stool testing was positive for Blastocytosis hominis. The enrollee is requesting coverage for a magnetic resonance imaging scan of the orbits, face, and neck. The enrollee reports she has an irregular heart rhythm and persistent chest pain. She asserts the magnetic resonance imaging scans are required to establish a proper diagnosis and make it possible for her to receive disease-specific therapy. Generally, the decision to pursue diagnostic imaging tests is based on clinical suspicion; including physical findings, presenting symptoms, laboratory results, and the persons history of illness. For this enrollee, the request for the magnetic resonance imaging scans seems arbitrary and not evidence-based. Records show the enrollees stool tested positive for Blastocystis hominis, a gastrointestinal parasite infection. Currently, controversy exists as to whether this parasite is truly pathogenic or a normal intestinal organism. There has never been a reported case of a disseminated Blastocystis hominis infection involving the orbits, face, or neck. Based on the above findings, there was no documented medical necessity for the requested magnetic resonance imaging scans.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for reimbursement for custom removable insert orthotics. The enrollee has bilateral foot pain. He was evaluated by a podiatrist. Records show the x-rays demonstrated degenerative changes and degenerative arthritis. The diagnosis was bilateral primary arthritis, foot pain, and difficulty walking. The enrollee reports the podiatrist prescribed the orthotics to prevent further medical issues. Other than the x-ray findings, there was no physical exam of the feet reported in the medical records for this visit that showed any clinical deformity of the feet, or prominence due to osteophytes, from the arthritic changes noted on the x-rays. Records do not show a history of failed treatments, use of oral non-steroidal anti-inflammatories or any history of steroidal injections for the arthritic joint causing the pain.  A review of the literature regarding custom foot orthotics reveals that, while many studies have been published, the results have been varied, and often inconclusive or negative in nature. Furthermore, the role of over-the-counter orthotics in the relief of pain has been extensively researched. One study found that over-the-counter orthotics have been found to be effective in relieving foot pain. Records do not show any conservative measures having been tried prior to the recommendation of the custom orthotics.Final Result: The reviewer determined that the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in podiatry 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 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 epidural steroid injection Current evidence based medical literature supports the use of epidural steroid injections as an effective treatment for radicular pain due to disc herniation. However, there is a lack of high-quality evidence demonstrating the effectiveness of epidural steroid injections for the treatment of radicular pain due to spinal stenosis. Additionally, there is a paucity of literature regarding repeat transforaminal epidural steroid injections. Murthy and colleagues concluded that most patients do not require repeat transforaminal epidural steroid injections for the treatment for lumbar radicular pain. This patient presents with complaints of severe low back pain and functional limitations. The medical records indicate that he has a history of low back pain radiating down the left lower extremity. Clinical examination findings document a positive straight leg raise on the left but no evidence of any focal neurologic deficit. He has undergone routinely scheduled lumbar epidural steroid injections over at least the past year. In this case, the patient experienced at least 50% pain relief and functional improvement following two injections. There is no clinical documentation of benefit in pain or function associated with the last injection. There is a lack of supporting medical evidence to support the safety and effectiveness of ongoing routine epidural steroid injections for the treatment of radicular low back pain. The records do not document any evidence of a lumbar spinal pathology such as disc herniation, to support a clinical indication for an epidural steroid injection. For these reasons, the requested epidural steroid injection is not medically necessary for treatment of this patient.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 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: An enrollee has requested authorization and coverage for Orthovisc injections (CPT J7324) to both knees.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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 when everything else has been tried and the options are limited. In this case, the patient has a history of lasting benefit from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties. Under these circumstances, Orthovisc injections (CPT J7324) to both knees are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 authorization and coverage for Gammagard. This patient has a history of mast cell activation syndrome and postural orthostatic tachycardia syndrome (POTS). Currently, immunoglobulin replacement therapy is not indicated for the treatment of mast cell disorders. There is a paucity of peer-reviewed medical literature or guidelines supporting an indication for immunoglobulin in this clinical setting. Available studies demonstrating improvement in patient health outcomes with immunoglobulin are small and retrospective. Castells and Butterfield noted that, Acute episodes of mast cell activation require epinephrine, and prolonged episodes may be addressed with corticosteroids. All told, Gammagard 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 subspecialty certification in allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for treatment from a naturopathic doctor (ND). The documentation provided supports that this patient has had chronic abdominal pain due to adhesions from previous intra-abdominal surgeries. The patient also has IBS status post partial colectomy. Her current treatment plan includes management by a gastroenterology, physical medicine, and surgery, as well as physical therapy. The documentation indicates the patient has been tolerating an oral diet and is working with a nutritionist. The provider recommended a nutritional supplement, UltraInflamX Plus 360. According to the current medical literature, the treatment for chronic abdominal pain in this clinical setting is surgery with lysis of adhesions. The documentation from the provider does not contain a physical examination, testing, a comprehensive assessment, or plan of care. The recommended treatment included a protein nutritional supplement, which is not the appropriate treatment for chronic pain due to abdominal adhesions and small bowel obstruction. All told, the requested treatment from an ND is not medically necessary for treatment of this patient.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 internal 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Optune System (HCPCS Code E0766). Optune System tumor treating fields (TTF) therapy is delivered locally through a physical, nonchemical pathway, which allows TTF therapy to treat brain tumors. The available data on the Optune System demonstrates that the device is safe and does not cause cumulative damage to healthy cells in the body. Lu and colleagues noted that the Optune System is focused to affect only one cell type at a time. Since the fields alternate rapidly, there is little effect on normal cells. This patient has been treated with resection, chemotherapy, and radiation with progressive disease. Consistent with the support in the current peer-reviewed medical literature, the patients provider recommended treatment with the Optune System. All told, the Optune System (HCPCS Code E0766) was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the Optune System (HCPCS Code E0766) was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the equipment at issue was and is 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: Physician reviewers 1, 2, and 3 are board certified in neurological surgery 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 Vertiflex Superion procedure (CPT code 22869). Interspinous process decompression offers an intermediate step in the continuum of care for patients with neurogenic intermittent claudication associated with lumbar spinal stenosis. There are many interspinous devices available. Current medical literature has not demonstrated that interspinous devices provide superior long-term symptomatic improvement over simple decompression. Although there is fair evidence that an interspinous spacer device is superior to nonsurgical therapy for one- or two-level spinal stenosis with symptoms relieved with forward flexion, insufficient evidence exists to judge the long-term benefits or risks. This patient has lumbar spinal stenosis. The standard of care for his condition remains simple decompression. For these reasons, the requested Vertiflex Superion procedure (CPT code 22869) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested Vertiflex Superion procedure (CPT code 22869) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for Norditropin Flexpro (somatropin) injection pen. The enrollee has CHARGE syndrome. She is status post cleft palate repair, status post ventricular septal defect repair, and she is tracheostomy and gastrostomy tube-dependent. She has additional diagnoses of developmental delay, myopia and sensoroneural hearing loss.  The enrollee was evaluated for short stature. Records show the enrollees height velocity over the previous 15 months was 6.1 centimeters per year.  A bone age x-ray showed a skeletal age of 11 years at a chronological age of 10 years three months, and open epiphyses, which predicts an adult height of 51 inches. The enrollee has a pretreatment height less than or equal to -2.25 standard deviations.  The enrollees height velocity and bone age would not allow the enrollee to reach a normal adult height. The enrollee therefore met idiopathic short stature criteria.  The request is consistent with generally accepted standards of medical practice.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatric endocrinology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for residential behavior health level of care. The enrollee entered a chemical dependency unit.  The enrollee has a history of multiple substance use, including heroin, alcohol, marijuana and methamphetamines, and reported abstaining from these substances for more than 30 days. The enrollee reported seizure activity prior to this admission. These were determined to be non-epileptic seizures. No seizure activity was observed during this admission. The enrollees vitals and withdrawal symptoms were monitored. Medications, group and individual therapy, and education were provided. The record revealed no acute withdrawal during this admission.  At discharge, records show the enrollee had achieved minimal progress in identifying triggers and cravings, depression, and family difficulties. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, treatment and recovery history, and acceptance and engagement. The enrollee has difficulties in relationships and with his ability to maintain responsibilities. He has not had success with previous treatment, but he does not currently engage in substance use. The enrollees composite LOCUS score is 21, which correlates with Level IV, medically monitored non-residential services.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting authorization and coverage for budesonide (Pulmicort) Flexhaler, 180 mcg. The enrollee has a medical history of asthma. Her symptoms include shortness of breath, wheezing, and cough. Her symptoms can wake her up from sleep. A progress note indicated the enrollee was tolerating her medications well and her average pulmonary function test result was 340. The physician notes the enrollee is trying to get pregnant and Pulmicort is the best inhaler for pregnancy. Literature reports that, because most published human gestational safety data available are for budesonide, this drug is considered the preferred inhaled corticosteroid for the treatment of asthma during pregnancy. However, inhaled corticosteroids other than budesonide may be continued in enrollees who were well controlled by these agents prior to pregnancy, especially if switching drugs could jeopardize control of asthma. Based on the enrollees stated intention to become pregnant, budesonide (Pulmicort) Flexhaler is the inhaled corticosteroid medication of choice.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.