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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computerized dynamic posturography (CPT 92548).Findings:  The physician reviewer found that Computerized dynamic posturography is an evaluation tool using a moving platform to assess a patients balance when impaired proprioceptive, visual, vestibular stimulation leads to symptoms such as loss of balance and falls. Patients who are recurrent fallers perform worse on the sensory organization test component of computerized dynamic posturography than patients who are non-fallers or one-time fallers. In the appropriate clinical setting, computerized dynamic posturography can help guide development of a safe exercise program and can help with early diagnosis and treatment planning of patients with intermittent claudication or Menieres disease. The records provided for review document that this patient with post-concussion neck and occipital pain does not have a diagnosis, history of falls, or loss of balance with daily functional activities to support an indication for computerized dynamic posturography. Currently there is a lack of quality research to support use of computerized dynamic posturography for patients with occipital pain, cervical pain, or vestibular symptoms resulting from concussion. For these reasons, the computerized dynamic posturography (CPT 92548) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the computerized dynamic posturography (CPT 92548) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation 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 Ultrasound guidance performed during trigger point injections. Within the records available for review, there is documentation that the patient is undergoing treatment for back pain. The provider performed trigger point injections with ultrasound guidance. However, while medical evidence identifies that ultrasound does allow for real-time imaging and can increase the success rate of injection, there is a lack of controlled studies to support this technique of ultrasound guidance as standard therapy. Medical literature noted that, ultrasound allows real-time imaging of the spread of the injectate around the relevant structures and increases the success rate of injection. However, in a more recent study, researchers concluded that, issues with clinical relevance, limited sample sizes, and small point estimates warrant more high-quality research to better characterize the possible value of ultrasound-guided injections. There is a need for additional clinical studies to evaluate the efficacy of using ultrasound guidance compared with the conventional technique of trigger point injection without ultrasound guidance. Given these findings, the ultrasound guidance performed during trigger point injections was not 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 ultrasound guidance performed during trigger point injections 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 reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine 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 external mobile cardiovascular telemetry. There is a lack of data in current medical literature supporting the use of real-time remote cardiac monitoring and definitively demonstrating its superiority to standard loop monitoring or event monitoring. In this case, the records did not document symptoms suggesting potentially life-threatening arrhythmias that would theoretically necessitate real-time monitoring for a possible immediate medical intervention. Therefore, external mobile cardiovascular telemetry was not likely to have been more beneficial for evaluation of the patient's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the external mobile cardiovascular telemetry at issue was not likely to have been 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 have been 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 is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Physician reviewers 2 and 3 are board certified in board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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 Fiasp Flextouch pen. As noted in the medical literature, most patients with type 1 diabetes follow a regimen of multiple daily injections of basal and bolus insulin (Janez, et al.). Fiasp is insulin aspart in a new formulation aiming to mimic the physiologic prandial insulin release more closely than currently available rapid-acting insulin products. The pharmacokinetic characteristics of Fiasp have the potential to better reproduce the fast endogenous prandial insulin secretion and thereby to improve postprandial glucose control in this patient population (Paquot and Scheen). The records provided for review document that this patient did not respond well to other bolus insulins in the past, but she is currently better managing her diabetes with Fiasp. In this clinical setting, there is adequate support for treatment of this patient with Fiasp insulin. Therefore, the requested Fiasp Flextouch pen is medically necessary for 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 subspecialty certification in diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Gelsyn-3 injection series in the right knee. Findings: 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 not responded to corticosteroid injections and desires to postpone a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Gelsyn-3 injection series in the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc-One (hyaluronan) injection in both knees. Findings: 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 chronic severe pain in both knees and has tried and failed other conservative treatments, including steroid injections, and surgical intervention. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc-One (hyaluronan) injection in both knees is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Ocrevus (ocrelizumab). Findings: The U.S. Food and Drug Administration (FDA) approves the use of ocrelizumab (brand name Ocrevus) for the treatment of patients with relapsing or primary progressive forms of multiple sclerosis (MS). The American Academy of Neurology practice guideline recommendations for disease modifying therapy (DMT) for adults with multiple sclerosis include offering DMTs to patients with relapsing forms of MS with recent clinical relapses or magnetic resonance imaging (MRI) activity. A study notes that in two phase III trials among patients with relapsing MS, ocrelizumab was associated with lower rates of disease activity and progression than interferon beta-1a over a period of 96 weeks. Another study notes that the results of a systemic literature search suggested that ocrelizumab has an efficacy superior to or comparable with all other currently approved DMTs across all endpoints analyzed, and a similar safety profile, indicating that it offers a valuable package for the treatment of patients with relapsing MS. In this case, the patient has a diagnosis of relapsing remitting MS, presenting with breakthrough disease activity and active lesions on MRI despite therapy with Gilenya, a DMT. In this clinical setting, given trying a different medication with a different mechanism or efficacy profile may be beneficial and as current medical literature shows ocrelizumab has an efficacy superior to or comparable with all other currently approved DMTs, the requested medication is medically indicated. Therefore, Ocrevus (ocrelizumab) was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for MC6000Tilt (all in one commode chair, tub access slider system and in-home mobility chair). Findings:  The physician reviewer found that At issue is whether the requested MC6000Tilt (all in one commode chair, tub access slider system and in-home mobility chair) is medically necessary to treat the patients medical condition. The submitted documentation supports that the requested DME is medically necessary. The patient has a history of mid cervical spinal cord injury with chronic tetraplegia, neurogenic bladder, and neurogenic bowel. She has been dependent for her self-care such as bathing, toileting, and dressing. She has been living in the community with caregiver assistance, using durable medical equipment such as a commode-shower chair. Given her level of injury and impairments, the patient does require significant truncal and limb support for safely sitting on equipment such as commode and shower chairs. Features such as cushioning and tilt-in-space are required because activities such as bowel care and showering can take prolonged periods of time, putting the patient at risk for pressure injuries as well as discomfort. Given that the patient has very limited limb and truncal control and she is dependent for transfers, transfers out of a tub (particularly when wet after a shower) are challenging and can be unsafe without appropriate precautions, which include proper equipment. Under these circumstances, the requested custom shower-commode chair with features such as tilt-in-space and slide transfer ability is medically necessary for this patient to safely accomplish her basic activities of daily living. Other equipment such as a standard commode chair and standard shower chair without these features is insufficient to meet the patients bathing and toileting needs safely and efficiently in the community. Accordingly, the requested MC6000Tilt (all in one commode chair, tub access slider system and in-home mobility chair) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested durable medical equipment is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested reimbursement for FoundationOne CDx. Soft tissue sarcomas, which include Ewing sarcomas, are rare and include a diverse group of tumors with differing treatments. Italiano and colleagues report that advances in molecular genetics of sarcoma have enabled the identification of type-specific aberrations and that molecular genetic testing assists in the diagnostic accuracy of sarcoma and appropriate clinical management. Given that the results of molecular profiling may be used to help guide treatment decision making, especially after exhaustion of standard therapies, including targeted therapies and clinical trials, the service at issue was likely to have been more beneficial than any available standard therapy. Therefore, FoundationOne CDx was likely to have been more beneficial for evaluation of the patient's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the FoundationOne CDx was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rituxan (rituximab). Findings: The American College of Rheumatology guidelines for the screening, treatment, and management of lupus nephritis, note that Rituxan may be used for the treatment of lupus nephritis when other standard treatments, such as Cellcept or Imuran, fail. In this case, given that the records indicate that the patient has a diagnosis of systemic lupus erythematosus (SLE) and hemolytic anemia, and has been unable to tolerate or had poor treatment response to standard therapies for  SLE, including Imuran and Cellcept, the requested medication is medically indicated. Therefore, Rituxan (rituximab) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing (CPT-81599). Findings:  Three out of three physician reviewers found that commercially available gene expression profiling (GEP) testing, such as the DecisionDx-Melanoma test, has been marketed as being able to classify cutaneous melanoma into separate categories used on risk of metastasis. However, it remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, micro satellites, and sentinel lymph node biopsy (SLNB) status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies (as have been performed in breast cancer) are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, SLNB, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models (i.e., the AJCC 8th edition melanoma risk calculator/prognostic tool in development). Accordingly, the DecisionDx-Melanoma test (CPT-81599) at issue was not likely to have been more beneficial than any available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in hematology and 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.