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  hybrid Maze procedure. This patient presents with paroxysmal atrial fibrillation with intermittent palpitations, an EF of 45%, and mild enlargement of left atrium. His provider has recommended a hybrid Maze procedure. The convergent, or hybrid Maze procedure, is a surgical ablation option for patients with atrial fibrillation that is considered when medical therapy and percutaneous ablative options have proven ineffective. When ablation is indicated, current guidelines do not recommend a hybrid surgical approach to ablation over conventional percutaneous ablation (Calkins, et al.). A hybrid approach to ablation has not been shown to be superior to existing accepted approaches in the treatment of atrial fibrillation. Maze procedures are considered when performed in conjunction with other heart surgery that already requires use of a pump, such as valve replacement or coronary artery bypass, neither of which this patient requires based on the records provided for review. Therefore, the requested hybrid Maze procedure 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 hybrid Maze procedure 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 reviewer 1 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 3 is board certified in cardiovascular disease with subspecialty certification in interventional cardiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for Cybernetics Food Anaphylaxis Panel by Foundation Labs LLC. Oral immunotherapy is not currently recommended as a standard care for treatment of food allergies. Researchers concluded that while significant progress has been made in the last decade in food allergen-specific oral immunotherapy, it is still in the very early stages of development and further investigations are necessary to optimize the protocols and improve safety while maximizing efficacy. Researcher notes that further investigation is needed to address current knowledge gaps including optimal dose, duration, age of initiation, maintenance schedule, mechanisms, predictors of risk and therapeutic response. Researchers reported that oral immunotherapy is associated with higher rates of systemic adverse events compared with other forms of immunotherapy, as well as a minor risk of eosinophilic esophagitis. Although several studies appear to have found benefits in oral immunotherapy, the interventions and end points used in these and other published trials vary widely, and either have not included controls or have used a cross-over design. As a result, neither the safety nor efficacy of oral immunotherapy has been definitively established. As such, oral immunotherapy, and the associated food-specific immunoglobulin E (IgE) testing, are not the standard of care for management of food allergies. Therefore, Cybernetics Food Anaphylaxis Panel by Foundation Labs LLC is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Cybernetics Food Anaphylaxis Panel by Foundation Labs LLC 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 reviewer 1 is board certified in allergy and  immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and pediatrics and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for first metatarsophalangeal joint (MPJ) cheilectomy, debridement and capsular release with Cartiva implant of the left foot. Based on the records provided for review, this patient underwent first MPJ cheilectomy with Cartiva implant of the left foot for hallux rigidus of the left first MPJ. The Cartiva implant is a synthetic implant placed within the first MPJ to treat osteoarthritis and hallux limitus. Current medical literature suggests that additional studies are needed to determine whether the Cartiva implant can provide superior health outcomes when compared to standard of care approaches such as arthrodesis of the first MPJ. Long-term data have demonstrated the safety and efficacy of arthrodesis with excellent and reproducible results. Therefore, first MPJ cheilectomy, debridement and capsular release with Cartiva implant of the left foot was 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 first MPJ cheilectomy, debridement and capsular release with Cartiva implant of the left foot (CPT code 28291) was 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 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 podiatry 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 biopsy of a right ovarian cyst and a hysterosalpingogram. The submitted documentation supports the medical necessity of a portion of the requested services. Ovarian cysts noted on ultrasound are typically followed with repeat scanning in six to eight weeks to monitor for resolution. In this case, the patient underwent a pelvic ultrasound that showed a small ovarian cyst that is consistent with a hemorrhagic cyst. There are no unique clinical circumstances noted in the submitted records that would support ovarian cyst biopsy, as this is not consistent with evidence-based standard of care. Therefore, the requested biopsy of the right ovarian cyst is not medically necessary to treat the patients medical condition.There is sufficient support for the requested hysterosalpingogram. A hysterosalpingogram is a standard diagnostic test for the work-up of infertility.  The diagnoses listed in the clinical documentation for this patient include infertility as an active problem. Therefore, a hysterosalpingogram is medically indicated to assess this diagnosis. Thus, the requested hysterosalpingogram is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 laser skin treatments (CPT codes 96920, 96921, and 96922).Findings:  The physician reviewer found that this atients records document trial and failure of two different topical steroids and a topical calcineurin inhibitor for at least three months for treatment of her vitiligo. In this clinical setting, excimer laser is approved as a device to treat vitiligo and has been demonstrated in the medical literature to be safe and effective. Bae and colleagues evaluated 159 patients with vitiligo and found that over 50% accomplished a 75% repigmentation when tacrolimus and steroids were used with the excimer laser. Do and colleagues reported that 56% of the 80 patients in their study with resistant vitiligo experienced partial repigmentation using the excimer laser. Given this support, the requested laser skin treatments (CPT codes 96920, 96921, and 96922) are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested laser skin treatments (CPT codes 96920, 96921, and 96922) are 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 reviewers 1, 2, and 3 are board certified in dermatology 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 patient has requested authorization and coverage for stress echocardiogram. Findings:  The physician reviewer found that The records report that this patient was referred by his provider for stress echocardiography for evaluation of his longstanding and extensive coronary artery disease (CAD). He is 25 years post coronary artery bypass graft (CABG) and has known occluded bypass grafts. Although he is asymptomatic at present, he has known un-revascularized disease with multiple occluded grafts and significant prior left ventricle (LV) dysfunction. Thus, reassessment of his LV ejection fraction, along with any ongoing ischemic burden, would be useful and beneficial to his management. If he has viable myocardium despite the depressed ejection fraction, his cardiac function may benefit from repeat cardiac catheterization and possible revascularization. Assessment of ongoing ischemia versus infarction by stress echocardiogram will help provide this information which would inform further treatment decisions. Given this support, the requested stress echocardiogram is medically necessary for this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in cardiovascular 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections for 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 bilateral osteoarthritis. He has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties in the presence of morbid obesity with associated increased cardiovascular risk. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injections for both knees 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 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: The patient has requested authorization and coverage for Entresto 24 mg - 26 mg tablets. Findings:  The physician reviewer found that the use of an angiotensin II receptor blockers (ARBs), such as losartan, is indicated during an acute heart failure event. The authors note that for patients on a low dose of ARB, a gradual titration approach maximized attainment of the target dose of Entresto (sacubitril/valsartan) for long-term management. In this case, the patient is recovering from heart failure and cardiogenic shock in the setting of acute nonischemic cardiomyopathy. The provider has instructed the patient to discontinue losartan and start on Entresto. Therefore, Entresto 24 mg - 26 mg tablets are 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 internal medicine with sub-specialty certification in cardiovascular 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cuvitru. Based on the available documentation, this patient demonstrates immunoglobulin G (IgG) deficiency, but she has levels of immunoglobulin A (IgA) and immunoglobulin M (IgM) that are within normal limits, which does not meet the criteria for common variable immunodeficiency (CVID). Although she has a history of waning pneumococcal antibody levels over time, she has responded adequately to the combination of Pneumovax and Prevnar with +10/14 serotypes or 71% serotypes with adequate values. Per the American Academy of Allergy, Asthma and Immunology (AAAAI), the records do not support specific antibody deficiency. In the absence of an indication for the requested treatment, Cuvitru 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for myocardial perfusion imaging and transthoracic echocardiogram. The patient has a multi-year history of chest discomfort. She has significant risk factors for coronary artery disease (CAD) including hypertension, hyperlipidemia, and systemic lupus. The records provided for review document that the patients most recent nuclear ischemic evaluation was in 2017. Evaluation has also included two echocardiograms in the past three years. The most recent echocardiogram was in March 2019, and it revealed normal left ventricle (LV) function, as well as no significant valvular heart disease, pulmonary hypertension, or pericardial effusion. Three years have passed since the patients last nuclear study and she remains at increased risk for CAD. Thus, a repeat nuclear ischemic study is indicated. However, in her most recent presentation, she lacked signs and symptoms concerning for LV dysfunction, pulmonary hypertension, valvular heart disease, or pericardial disease. The patients two echocardiogram studies were interpreted as normal. There is no reported intercurrent myocardial infarction, change in electrocardiogram or symptoms, or hypotension. Therefore, a repeat echocardiogram is not appropriate based on clinical presentation and published guidelines. Therefore, the requested myocardial perfusion imaging is medically necessary, while the requested transthoracic echocardiogram is not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services is 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 internal medicine with subspecialty certification in cardiovascular 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for allergy testing. Given the history and physical examination findings noted in the medical records, the likely diagnosis for this patients skin condition is atopic dermatitis (AD). There is adequate evidence in the medical literature to support testing for foods to help determine the aggravators of the underlying disease in this clinical setting. Researchers found that, The diagnosis of food allergy in AD is currently based on the clinical history, skin prick tests, or blood test screening, followed by an elimination diet and/or standardized oral food challenge. For this patient, it is appropriate to perform food allergy testing to rule out any potential food triggers. Accordingly, the requested allergy testing is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for infusions of Privigen.Researchers conducted a study to assess the impact of treatment with intravenous human immunoglobulin (IVIG) on the outcome of BK virus-associated nephropathy (BKVN) in renal transplant recipients. BKVN can cause clinically significant viral infection in renal transplant recipients, leading to allograft dysfunction and loss. Vu and colleagues found that IVIG administration appeared to be safe and effective in treating BKV viremia and BKVN and preventing graft loss in patients who had inadequate response to immunosuppression reduction and leflunomide therapy. In this case, the patient has elevated BK viremia in the setting of a renal transplant, and immunosuppression has been reduced with persistent viremia. In addition, cidofovir would have concerns with regards to renal toxicity. IVIG has been shown to improve graft survival under these circumstances and has been shown to be safe. Accordingly, the requested infusions of Privigen are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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.