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

Nature of Statutory Criteria/Case Summary: At issue is whether interspinous and interlaminar stabilization/distraction devices (spacers)are likely to be more beneficial for treatment of the patients condition than any available standard therapy. His symptoms have included ongoing pain in the back with radiation to the lower extremity associated with numbness and weakness in the lower extremities. He has failed at least six months of conservative treatment with non-steroidal medications, opioid pain medications, physical therapy, epidural steroid injection, and bracing.Two out of three physician reviewers four that nationally recognized evidence-based medical guidelines do not recommend the use of interspinous decompression device over decompression surgery (laminectomy), the gold standard for lumbar spinal stenosis. Current evidence-based medical guidelines and peer reviewed literature do not fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this patients medical condition. There is no discussion relative to why this patient would not be indicated for standard decompression surgery, other than his preference to avoid invasive surgery. Additionally, Food and Drug Administration (FDA) criteria have not been met for the use of this device.Final Result: The reviewers determined that the requested interspinous and interlaminar stabilization/distraction devices (spacers), is 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 board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a positron emission tomography (PET) scan. The use of positron emission tomography (PET) using 19-FDG in the evaluation of dementia has been the subject of ongoing studies. In clinical practice, the largest role of PET of the brain has been to use the technology to differentiate between patients with dementia who have features of both Alzheimers and frontotemporal dementia, when a diagnosis cannot be made on a clinical basis alone. The utility of PET is more limited in the initial evaluation of patients with cognitive complaints. This patient has a history of reported cognitive issues with onset. She previously underwent neuropsychological testing with varying results. The results of her testing suggested the patients cognitive ability was above average to superior in all domains. She was evaluated by neurology and the patients provider noted that Alzheimers dementia was among the differential diagnoses for the patients condition. Given the technological and clinical limitations of PET imaging, the PET scan performed was not likely to be more effective than the use of other clinical techniques for the assessment of the patients cognitive complaints. Final Result: Two of the three 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:  One reviewer is board certified in neurology and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that as noted in the medical literature, one crucial element of success in treating eating disorders with complex and comorbid psychiatric issues is sustained coping strategies such as dialectical behavior therapy (DBT). Moreover, the patient must become able to refeed herself independently and have a strong support system to transition to a less restrictive level of care. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment (Klaehn, et al). Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the appropriate level of care. Applying the CALOCUS to this patients presentation, treatment at the RTC level of care is supported as medically necessary. The patient has a composite score of 23, which is consistent with non-secure 24-hour services with psychiatric care, such as RTC level of care services. Given this support, the RTC services provided were and are medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were and 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 subspecialty 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections to both knees.Hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis that is significantly symptomatic who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical evidence supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Per the current medical evidence, if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to perform another series. In this case, the patient presented with increasing left anteromedial knee pain and right knee mild swelling and tenderness. Clinical examination findings documented functional range of motion with crepitus. There was radiographic evidence of early osteoarthritic changes with small osteophytes appearing medial and laterally. She had reportedly failed to achieve adequate improvement with rest, physical therapy, home exercise program, and corticosteroid injections. The records noted that prior Synvisc injections to the left knee did not provide significant benefit. A recent right knee magnetic resonance imaging demonstrated evidence of right knee osteoarthritic changes, severe in the medial compartment. Current evidence-based criteria have been met for the requested Synvisc injections to the right knee. There is no documentation of significant improvement in symptoms for six months or more following Synvisc injection to the left knee to support repeat injections. Therefore, Synvisc injections to the right knee are medically necessary for the treatment of this patient. The medical necessity of Synvisc injections to the left knee has not been established. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tests (Foundation Medicine CDx + PD-L1, OmniSeq Immune Report Card, NantOmics GPS Cancer and/or Guardant360). As noted in the medical literature, NGS uses sequencing of multiple DNA fragments, performed in parallel, in patients with a known, biopsy proven malignancy. NGS is reserved for clinical scenarios to determine the sequences of multiple genes. Castlemans disease is typically diagnosed using tissue biopsy of an affected area such as a node. As this patients records do not include documentation of a tissue diagnosis to confirm a malignancy, including Castlemans, NGS is not indicated. The requested tests are used to help determine treatment and are not routinely utilized for diagnosis. As this patient does not carry a tissue diagnosis of malignancy, the requested tests (Foundation Medicine CDx + PD-L1, OmniSeq Immune Report Card, NantOmics GPS Cancer and/or Guardant360) are not medically necessary. 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 certifications in medical oncology and hematology 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 diagnoses that include polyneuropathy, morbid obesity, spina bifida and paresthesia of skin. She uses a wheelchair for ambulation but has limited ambulation inside her home. The patient reported edema in both lower legs. The physical examination revealed edema in the lower extremities. No skin lesions or abnormalities were documented in the physical examination. The patient has requested coverage for compression stockings. The Health Plan denied the request and reported compression stockings were not medically necessary for the treatment of this patient. At issue in this case is whether compression stockings are medically necessary for the treatment of this patients medical condition. This patients records do not include a clinical diagnosis or physical examination findings that support a diagnosis of venous insufficiency or lymphedema. In addition, there is no diagnosis of deep vein thrombosis (DVT), no documented concern for DVT, and there was no evaluation ordered for DVT. Compression stockings are appropriate to manage edema due to venous insufficiency, lymphedema and DVT. However, compression stockings are not indicated to manage edema as a symptom without identifying the cause. Thus, compression stockings are not medically necessary to treat this patients medical condition.Final Result: The reviewer determined that the requested service 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 practice 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

At issue is whether a genicular nerve block and medial branch nerve radiofrequency ablation are likely to be more beneficial for treatment of the patients condition than any available standard therapy. The enrollee has been diagnosed with chronic left knee pain.  In this case, the patient has tried and failed multiple forms of conservative management, including physical therapy, joint bracing, intra-articular steroid injections, and viscosupplementation injections.  Pain and functionality has not been improved with medication management, including acetaminophen, tramadol, and gabapentin. The patient is not able to use nonsteroidal anti-inflammatory drugs. Her provider noted that the patient was not a good surgical candidate for joint replacement therapy due to venous status and her comorbid conditions.   Genicular nerve blocks RFA provide a minimally invasive treatment to bring pain relief to patients with chronic knee pain. Genicular nerve blocks RFA has been shown to provide significant benefit to well-selected patients by relieving knee pain, increasing functionality, and decreasing the need for pain medication.  Based on the review of literature, a genicular nerve block and medial branch nerve RFA are likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy.Final Result: The reviewers determined that the requested treatment is 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 anesthesiology with sub-specialty certification in pain management, and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections. Findings:  Two of the three physician reviewers found that there is sufficient support for the requested services in this clinical setting. The records document pelvic pain, muscle spasm, pelvic floor dysfunction and vulvar vestibulitis. This patient has continued to experience symptoms despite treatment with physical therapy, Valium suppositories and trigger point injections. The records document chronic pelvic pain which has not improved with the standard course of treatment. The medical literature supports Botox injections as the next step in this clinical setting. Therefore, the requested Botox injections are likely to be more efficacious than other treatment options. 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 obstetrics and gynecology 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 patient requested authorization and coverage of Uloric 40 mg. At issue in this case is whether the requested Uloric 40 mg is medically necessary.Findings:  The physician reviewer found that the current American College of Rheumatology (ACR) guidelines recommend xanthine oxidase inhibitor (XOI) therapy with either allopurinol or febuxostat (Uloric) as the first-line pharmacologic approach for management of gout. In addition, a reported that for patients with gout and major cardiovascular coexisting conditions, febuxostat was noninferior to allopurinol with respect to rates of adverse cardiovascular events. In this case, the patient has a history of gout. However, the records do not include laboratory work or aspiration of joint with crystals to support a diagnosis of gout. Further, the patient is noted to have conditions in which the use of Uloric would be concerning given the recent studies demonstrating and increased risk of cardiovascular event in patient with similar comorbidities. Moreover, the medical records fail to demonstrate a contraindication or failure of formulary alternatives. Given the available documentation, Uloric 40 mg is not medically necessary for treatment of this 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 subspecialty certifications 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a wheelchair accessory power standing system. Findings:  Two physician reviewers found that as discussed in the current peer-reviewed medical literature, there is a paucity of consistent high quality studies demonstrating improved patient outcomes with use of standing frames. Further studies are needed to adequately evaluate the potential benefits of standing devices. Although the device is reported to provide positive effects in terms of spasticity, pain, and improved bone metabolism, the studies performed were limited in sample size and lack long-term follow-up. Furthermore, existing bone mineral density loss and osteoporosis might cause fractures in patients who stand prematurely and without a well-designed progressive standing program. The documentation provided for review reveals that this patient has osteoporosis, scoliosis, and contractures, all of which are noted to be precautions and/or possible contraindications to a standing device. Additionally, there is no indication that she has undergone assessment to determine her current standing tolerance. These precautions and the possibility of fracture or inability to tolerate the requesting standing device may make the patient more susceptible to falls. All told, the requested wheelchair accessory power standing system is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested equipment is 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:  One reviewer is board certified in physical medicine and rehabilitation and is actively practicing. One Reviewer is board certified in physical medicine and rehabilitation and is actively practicing.  One Reviewer is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has been diagnosed with osteoporosis and gastritis and is requesting anabolic therapy with Tymlos. Findings:  The physician reviewer found that the requested services are not medically necessary for treatment of the enrollee's medical condition. Therefore, the Health Plans denial should be upheld.  The enrollee has age-related osteoporosis and requires surgical intervention once her bone mineral density (BMD) has improved. The enrollee has had a significant BMD decline of 6.1% since 2014. The enrollee has a lumbar spine T-score of -3.4, which is consistent with osteoporosis, and left hip T-score of -2.5, which is consistent with osteopenia. Previous therapies that have been tried and failed include calcium and vitamin D supplement. The provider noted that oral bisphosphonates are contraindicated due to Barretts esophagus without dysplasia. Tymlos therapy is an anabolic medication which can lower the risk of osteoporotic fractures by improving the bone strength. This patient has post-menopausal osteoporosis but does not have a history of fragility fractures. She has a documented decrease in BMD scores, however, she has not previously been treated with anti-resorptive therapy for osteoporosis. Specifically, the enrollee has not reportedly tried and failed therapies like Prolia or Reclast prior to considering anabolic therapy such as Tymlos (Cosman, et al.). Therefore, anabolic therapy with Tymlos is not supported as medically necessary for treatment of this enrollees medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheldCredentials/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.