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 a Stimwave peripheral nerve stimulator implant device.Findings:  Three physician reviewers found that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. While there has been progress made in the field of peripheral nerve stimulation over the past two decades, the literature on peripheral nerves that is not associated with headaches consists of case series and individual case reports. The literature is silent on this particular combination of peripheral nerves and the efficacy of peripheral nerve stimulation on the right hip femoral and obturator articular branch nerves. Under these circumstances, a Stimwave peripheral nerve stimulator implant device is not likely to be of greater benefit than other treatment options.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 other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are actively practicing and are board certified in anesthesiology, with subspecialty certification in pain medicine. 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 DecisionDx-Melanoma assay. Findings:  Three physician reviewers found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system. Mitotic rate may add to these statistics. DecisionDx-Melanoma assay is a study of 31 genes in an individuals melanoma cells. DecisionDx-Melanoma assay classifies that particular melanoma based on the risk of metastasis over five years. On 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Additionally, it is not clear if the DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, DecisionDx-Melanoma assay was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 10/325 110 pills per month and Zofran 8mg 40 pills per month. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees rheumatoid arthritis. At issue in this case is whether the requested medications, Norco 10/325 110 pills per month and Zofran 8mg 40 pills per month, are medically necessary for treatment of the enrollees medical condition.The Centers for Disease Control clinical practice guidelines do not support the use of opiates in non-malignant pain. The American College of Rheumatology Guideline for the treatment of rheumatoid arthritis also does not include opiates as a treatment modality. The opiates should be tapered and the restricted dispensing is appropriate. As the opiate is tapered, there should be less need for the Zofran and this should be tapered along with the opiate. Therefore, the requested medications Norco and Zofran are not medically necessary.Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for dopamine transporter single-photon emission computed tomography (DaT SPECT) scan.Findings:  Two of the three physician reviewers found that DaT SPECT scans have been shown to be useful in cases where the diagnosis of idiopathic Parkinsons disease versus essential tremor is being considered. For this patient, the exact diagnosis was not clear. In addition, his symptoms were resistant against therapeutic intervention. It is imperative to provide a definitive diagnosis, as treatment for Parkinsons disease and essential tremor are quite different. In this particular case, the patients care was assisted by this study, as it was able to exclude the diagnosis of Parkinsons disease. Thus, DaT SPECT scan was likely to have been of greater benefit than other available methods of evaluating this patient. Final Result: The reviewers determined 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 reviewers 1, 2 and 3 are board certified in neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for enteral formula (Ensure nutritional drinks). The Health Plan has denied this request indicating that the requested nutritional drink is not medically necessary for treatment of the enrollees irritable bowel syndrome. A review of the record indicates that the enrollee has been diagnosed with somatoform disorder; gastritis; fibromyalgia; anxiety; weight loss; post-traumatic stress disorder; anorexia; gastroduodenitis without bleeding; and irritable bowel syndrome without diarrhea. A visit note, reported the enrollee presented with weight loss and abdominal pain. The enrollee reported a visit in the emergency room, for abdominal pain and nausea. The enrollee reported severe constipation and daily laxative use and takes a laxative every time she eats solid food. The enrollees weight at this visit is 99 pounds, height 5 feet 3 inches and body mass index (BMI) is 17.5. The provider recommends following up with a psychiatrist; continue Maxalt and ondansetron; follow up with gastroenterology; and smaller more frequent meals; Ensure; and protein shakes. At issue in this case is whether the requested enteral formula (Ensure nutritional drinks) is medically necessary for treatment of the enrollees medical condition. Ward notes that patients with irritable bowel syndrome may benefit from exclusion of gas-producing foods; a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs); and in select cases, lactose and gluten avoidance. The patient has a diagnosis of irritable bowel syndrome with constipation. There is no documentation of a trial of standard dietary intervention for irritable bowel syndrome or documentation of other medical management of irritable bowel syndrome. Therefore, the use of an enteral formula is not medically necessary.Final Result: The reviewer determined that the requested nutritional drink 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 family medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prometheus Anser IFX blood testing. Findings: Two of the three physician reviewers found that the Prometheus Anser IFX blood testing was not indicated under these circumstances. The Prometheus Anser IFX blood test has not definitively demonstrated efficacy for the management of Crohns disease. The presence of antibodies alone does not necessarily result in loss of response to infliximab or infusion reactions, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. The current medical literature lacks high-quality controlled studies to define drug level or antibody level thresholds requiring action, compare clinical strategies (such as dose increase or change in medication) based on those thresholds, and then definitively establish that use of Anser IFX improves outcome. The test can be redundant with other methods of disease assessment, such as enteroscopy and magnetic resonance enterography, which were used for decision-making in the case. For these reasons, the Prometheus Anser IFX blood testing performed for this patient was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in internal medicine, with subspecialty certification in gastroenterology, and all three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested genetic testing. Findings: Two of the three physician reviewers found there is sufficient support for the services at issue in this patients case. Noninvasive prenatal screening by cell-free DNA is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is a sensitive screen for aneuploidy and does not require the invasive procedure of chorionic villus sampling or amniocentesis. Therefore, genetic testing was likely to be of greater benefit than other methods of evaluating this patient. 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 reviewers 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewers 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewers 3 is board certified in obstetrics and gynecology 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: An enrollee has requested reimbursement for spinal fusion surgery. In the medical literature, Resnick and colleagues recommend surgery for spinal stenosis for patients who do not improve with conservative treatment. Numerous studies have demonstrated the role of surgical decompression in this patient population. However, few studies have investigated the utility of fusion in patients without underlying instability. The inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. In addition, Weinstein and colleagues reported on a clinical trial comparing the effectiveness of surgery for spinal stenosis to non-surgical treatment. The authors concluded that patients who underwent surgery showed significantly greater improvement in all primary outcomes than patients who were treated non-surgically. Similarly, Kovacs and colleagues concluded that decompressive surgery, with or without fusion, was more effective for patients with symptomatic lumbar spinal stenosis than continued conservative treatment following failure of three to six months of conservative treatment. This patient had a history of chronic low back radicular pain. She had failed extensive non-operative treatment including epidural, sacroiliac, and facet joint injections, as well as medications. Further care has included activity modification, physical therapy, and a home exercise program. She presented to the emergency department after sustaining a fall at home due to severe low back pain and lower extremity weakness. Clinical examination findings documented motor and sensory deficits consistent with reported imaging evidence of L4-5 herniated nucleus pulposus, lateral recess stenosis, and facet joint hypertrophy. There was reported radiographic evidence of spondylolisthesis at the L4-5 level with 5 mm of spinal segmental instability on flexion and extension x-rays. Given the severity of the patients pain and worsening lower extremity neurologic signs, surgical intervention consisting of L4-5 decompression and fusion with instrumentation was indicated. Based on review of the medical records and consistent with evidence-based medical criteria, the L4-5 decompression and fusion was medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the service at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: A 63-year-old male enrollee has requested authorization and coverage for continued skilled nursing facility services from November of 2018 through December of 2018 including the assistance of multiple caregivers to provide the enrollee with physical therapy two times per day to combat paralysis; getting into and out of bed from a wheelchair and support sitting up; showering; changing his involuntary bowel movements three to four times daily; and daily dissemination of medication for blood pressure and diabetes. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees hypertension; diabetes mellitus type two; cauda equina syndrome; and postlaminectomy syndrome.At issue in this case is whether the requested continued skilled nursing facility services from November of 2018 through December of 2018 including the assistance of multiple caregivers to provide the enrollee with physical therapy two times per day to combat paralysis; getting into and out of bed from a wheelchair and support sitting up; showering; changing his involuntary bowel movements three to four times daily, and daily dissemination of medication for blood pressure and diabetes are medically necessary.Spinal cord or cauda equina compression (e.g., due to an acutely herniated disc) can result in profound functional impairments such as paraplegia, bladder dysfunction and bowel dysfunction requiring individualized rehabilitative measures and supportive care. For cauda equina syndrome, early surgical decompression is the mainstay of treatment. In the present case, the patient underwent surgical decompression and was transferred to a skilled nursing facility for rehabilitation. He has been undergoing rehabilitation since mid-October of 2018, with a brief acute hospital readmission due to urinary tract infection.The patient has made some functional progress but has plateaued at ambulating short distances with a walker at the contact guard assistance level and requiring significant assistance for his lower body self-care. He is bladder continent and remains incontinent of bowels requiring assistance for bowel care and clean up. Ongoing care after the end of November of 2018 can be provided at a less intensive rehabilitation setting such as the community with home/outpatient rehabilitation services and custodial level assistance at home. Therefore, the services in question are not medically necessary.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 physical medicine and rehabilitation 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: A 64-year-old male enrollee has requested authorization and coverage for the medication HP Acthar gel (Corticotropin Inj Gel 80 U/ML) for treatment of the enrollees ankylosing spondylitis of the cervical region. Findings:  The physician reviewer found that At issue in this case is whether the requested HP Acthar gel (Corticotropin Inj Gel U/ML) is medically necessary for treatment of the enrollees medical condition.This is a case of ankylosing spondylitis with recent flare. Treatment thus far has included Humira, methotrexate, naproxen and Medrol. The request is for Acthar gel. Calhouf and colleagues indicate that compared with placebo, tumor necrosis factor blockers improve disease activity and provide clinically meaningful functional capacity for patients with ankylosing spondylitis. Assessment in SpondyloArthritis International Society (ASAS) guidelines also supports the use of tumor necrosis factor blockers for the treatment of ankylosing spondylitis. In this case, the patient has no history of allergy or contraindication to tumor necrosis factor blockers or other standard therapy. The notes state that there is improvement with Humira. The requested medication, Acthar gel, does not have a Food and Drug Administration approved indication for ankylosing spondylitis. There are no guidelines or recommendations for this medication to be used in a case such as this. The medical records fail to demonstrate that Acthar gel is medically necessary for the treatment of this patient's ankylosing spondylitis. 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 in internal medicine with subspecialty certification in allergy and immunology and rheumatology 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 acupuncture services. Researcher found in a recent study comparing usual care to acupuncture plus usual care found that at 24 months the acupuncture/usual care subjects were significantly more likely to report 12 months pain-free and less likely to report they required use of medication for pain. Researchers noted that acupuncture has been found to be more effective than no treatment for short-term pain relief in chronic low back pain. Given that the patient continues to be symptomatic, an acupuncture trial for pain management and function improvement would be reasonable, and is supported by peer review literature. Therefore, acupuncture services are supported as medically necessary.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 oriental 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 for prenatal genetic tests.Findings:  Two of the three physician reviewers found that testing for common recessive genetic disorders in pregnancy allows patients to make important medical decisions. If the patient is positive for a particular mutation, then testing for their partner may be offered. This allows for eliminating the potential to have an affected offspring with a serious genetic disorder. In this case, the services at issue revealed that the patient was a carrier for Fanconi anemia type C. Carrier testing is supported by the American College of Obstetricians and Gynecologists. Thus, prenatal genetic tests were likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were 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 clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology 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.