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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX procedure (CPT 43284). Lipham and colleagues note in a multicenter, prospective, single-arm study of 44 patients, that sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits without safety issues, as demonstrated by reduced esophageal acid exposure, improved quality of life related to gastroesophageal reflux disease (GERD), and cessation of dependence on proton-pump inhibitors (PPIs), with minimal side effects and no safety issues. However, Sheu and Rattner note that the long-term safety and efficacy of LINX  both alone and compared to current GERD therapies  remains to be determined. Bauer and colleagues note the possibility of adverse events, including erosion through the esophagus. While the U.S. Food and Drug Administration (FDA) approves the use of the LINX Reflux Management System for patients diagnosed with GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite medical therapy for the treatment of reflux, based on current evidence and medical literature, the technology has not met a consensus opinion or recommendation by medical societies and governing organizations. The requested service has not been rigorously tested in randomized controlled trials against alternative therapies and therefore, it is not possible to establish an individualized benefit in this case. Due to the lack of consensus among national and local health care providers, there are no set standard protocols regarding the terms and conditions for use. Therefore, a LINX procedure (CPT 43284) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested LINX procedure (CPT 43284) 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 service is 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for liposuction and an abdominoplasty.Findings:  The physician reviewer found that World Professional Association for Transgender Health (WPATH) standard of care lists as treatments for gender dysphoria for transgender men: Nongenital, nonbreast surgical interventions: voice surgery (rare), liposuction, lipofilling, pectoral implants, and various aesthetic procedures. Additionally, WPATH states, Non-genital surgical procedures are routinely performed.these surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. In this case, the patient has been diagnosed with gender dysphoria. Records indicate that the patients abdominal contour contributes to his gender dysphoria. Thus, liposuction and an abdominoplasty are medically necessary for treatment of 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 psychiatry with expertise in transgender 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for an inpatient hospital stay.Candidates for surgical repair of pelvic organ prolapse are women with symptomatic prolapse who have failed or who have declined conservative management. Hysterectomy is often performed at the time of pelvic organ prolapse repair. Definitive management with hysterectomy, including repair of cystocele and rectocele, is done electively to improve the quality of life for these symptomatic women. This surgical procedure is performed in the surgical center with a planned period of observation anticipated to be less than 48 hours for postoperative recovery. In this case, the patient will be undergoing an elective hysterectomy with cystocele/rectocele repair for worsening pelvic organ prolapse. However, there are no unique clinical circumstances in the patients medical history that would warrant acute inpatient admission for her postoperative recovery. The patient can be expected to be safely and effectively cared for under an observational level of care. Therefore, the requested inpatient hospital stay is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care (MAC) services. Findings:  The physician reviewer found that current guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) for sedation and anesthesia in gastrointestinal endoscopy noted that, We recommend that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events (Early, et al.). In addition, the ASGE stated that, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Wernli and colleagues concluded that the use of anesthesia was associated with a 13% increase in the risk of any complication within 30 days and was associated specifically with an increased risk of perforation, hemorrhage, abdominal pain, complications secondary to anesthesia, and stroke. In this case, the patient presented for a routine esophagogastroduodenoscopy and colonoscopy. The patient did not have any documentation of significant heart, lung, kidney, or liver disease. There is no documentation of a history of alcohol or substance abuse, or detailed description of previous history of difficulties with anesthesia or sedation with past colonoscopies. The patient was given an ASA classification score of 1 and there is no evidence that she presented with a difficult airway. The ASGE guidelines do not support the use of MAC services in this patient who does not have significant health conditions or airway concerns. Based on these findings, the MAC services were not medically necessary for this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a supervised sleep study in a lab. Findings:  The physician reviewer found that records provided for review document that this patient presents with sleep maintenance insomnia primarily secondary to obstructive sleep apnea (OSA). The patient could also have periodic limb movement disorder as a contributing factor to her insomnia. As the patient is symptomatic and has moderate OSA, treatment with continuous positive airway pressure (CPAP) therapy is appropriate. The American Academy of Sleep Medicine (AASM) recommends in-lab titration of CPAP in this clinical setting. However, the requested diagnostic supervised sleep study to be performed in a lab is not indicated as the patient was already diagnosed with OSA and additional testing will not add to her management. Therefore, the requested supervised sleep study in a lab is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral genicular nerve block with ultrasound guidance. This patient presents with ongoing knee pain with imaging demonstrating progression of severe right patellofemoral arthrosis, moderate joint effusion with synovitis, and a large Bakers cyst with synovitis. The provider has recommended treatment with genicular nerve blocks. Genicular nerve blocks and genicular nerve ablations have been demonstrated to be effective in the treatment of patients with chronic knee pain. Studies have demonstrated that when a patient experiences significant pain relief and functional benefit with genicular nerve blocks, ablation of the nerves can provide longer-term pain relief (Fitzpatrick, et al.; McCormick, et al.). The requested genicular nerve block is a minimally invasive procedure compared to knee surgery and is indicated to be performed as a treatment option prior to more invasive surgery. Therefore, the requested bilateral genicular nerve block with ultrasound guidance 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 requested bilateral genicular nerve block with ultrasound guidance 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 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: Physician reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain management 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Xyosted auto-injection 75 mg/0.5 mL.Endocrine Society and European Association of Urology guidelines state that two morning testosterone level below reference range are recommended prior to initiation of therapy for hypogonadism. Guidelines recommend measurement of luteinizing hormone (LH) levels and follicle stimulating hormone (FSH) to evaluate the type of hypogonadism. Additionally, guidelines also state patients should have classical androgen deficiency symptoms. Moreover, the guidelines recommend monitoring testosterone, hematocrit, prostate-specific antigen, and lipid profile continuously after initiating testosterone replacement therapy. In this case, the patient did not have two morning testosterone levels tested. Additionally, LH and FSH levels were not documented. Clinical documentation supporting continuous monitoring of testosterone replacement therapy is not available. There is inadequate documentation to support the diagnosis and type of hypogonadism. Therefore, Xyosted auto-injection 75 mg/0.5 mL is not medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for artificial disc replacement surgery for C4-5, C5-6 and C6-7. Current medical literature supports the use of multilevel cervical disc arthroplasty at three or four levels. In an evaluation of 159 cervical disc arthroplasties (CDAs), Gornet and colleagues concluded that statistical improvement in patient-reported outcomes, with a low rate of secondary surgeries out to seven years, demonstrated that three and four level CDAs were safe and effective in appropriately selected patients. Reinas and colleagues report that multilevel CDA provides good clinical and radiological outcomes, preserving motion in the cervical spine and preventing adjacent segment degeneration, while having a beneficial effect on sagittal balance. The authors further note that these results are true for two to four levels, making the procedure a valuable option in patients with cervical multilevel degenerative disc disease. In this case, the records document the presence of degenerative disc disease with radiculopathy at multiple levels despite conservative treatment and the severity of the symptoms. Given that current medical literature supports the use of the requested service as effective for pain relief, improvement of function, preservation of motion, and long-term efficacy, the requested service is medically indicated. Therefore, artificial disc replacement surgery for C4-5, C5-6 and C6-7 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for chronic COVID-19 program services.The submitted documentation fails to demonstrate the medical necessity of the requested services. In this case, there is a lack of evidence demonstrating that this patient has had COVID-19. Therefore, the records do not establish that her symptoms are related to long COVID. Post-COVID-19 clinics usually include physical therapy and behavioral counseling. The clinic she is attending is using highly unconventional therapy and would not be mainstream in terms of its care. Per the submitted documentation, the described drug regimen used there includes ivermectin, prednisone, Maraviroc and fluvoxamine. These are, respectively, an anti-parasitic drug, an anti-inflammatory agent, an anti-human immunodeficiency virus (HIV) drug and an antidepressant. There is a lack of support for the requested services in this patients case. Therefore, chronic COVID-19 program services are not medically necessary for the 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 internal medicine with sub-specialty certification 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued use of a continuous positive airway pressure (CPAP) machine (HCPCS code E0601) and humidifier (HCPCS code E0562). Patil and colleagues strongly recommend the use of CPAP therapy for ongoing treatment of obstructive sleep apnea (OSA) in adults. In this case, the patient has a diagnosis of severe OSA and a history of childhood asthma. The submitted records documented that the patent is compliant with CPAP therapy. Given that OSA is a chronic disease requiring treatment that, left untreated, may exacerbate the patients asthma and cause major health issues such as hypertension, cardiovascular disease, and stroke, the requested equipment is medically indicated. Therefore, continued use of a continuous positive airway pressure (CPAP) machine (HCPCS code E0601) and humidifier (HCPCS code E0562) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 internal medicine 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: The patients parent has requested authorization and coverage for occupational therapy. Medical literature notes that occupational therapy services may be indicated in the management of children with autism spectrum disorder (ASD) to promote fine motor and adaptive skills, including self-care, toy use, and handwriting. The authors further note that two-thirds of preschool-aged children with ASD are reported to receive occupational therapy services. In this case, the patient was receiving weekly occupational therapy and occupational therapy notes reported that the patient was making progress toward therapy goals. While an occupational therapy evaluation reported that the patient did not participate in adult led tasks, in an undated letter, the patients mother reported that the patient tended to shut down and become uncooperative in unfamiliar situations due to sensory overload. In this case, given that an assessment by an unfamiliar therapist may be inadequate to ascertain the patient's potential to benefit for occupational therapy, and as the records documented that the patient was making progress toward her therapy goals, the requested services are medically indicated. Therefore, occupational therapy 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 neurology with special qualification in child 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for 30 Veltassa 8.4 g packets a month.Most individuals with hyperkalemia have chronic kidney disease or are treated with a medication that inhibits the renin-angiotensin-aldosterone system (RAAS). Mild-to-moderate hyperkalemia (5.5-6.5mEq/L) should be treated with dietary modification, diuretics, and treatment of chronic acidosis. If this is not effective, then the medications that inhibit the RAAS should be reduced or discontinued. If this treatment is not effective, then potassium binders can be utilized. Patiromer (Veltassa) can be used in hyperkalemic emergencies when the potassium must be lowered quickly, as it can be effective within an hour. In this case, there is no indication that loop diuretics have been contraindicated in this patient in an outpatient setting. There is no indication that any steps have been taken to prevent the hyperkalemia without a potassium binder medication. Thus, the requested 30 Veltassa 8.4 g packets a month are not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in child and adolescent 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.