Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for GeneSight genetic testing. Findings:  The physician reviewer found that current peer-reviewed medical literature, GeneSight genetic testing based on investigating polymorphisms on cytochrome P450 which are unique for each individual, is medically necessary for evaluation of this patient. The GeneSight genetic test is personalized to an individual patient to help assess the rate of drug metabolism and guide medication regimens and dosing (Garcia-Gonzalez, et al.; Daly). Dawes noted that, pharmacogenetic information has been introduced in response to the unpredictability of medication, the high number of adverse drug events, and lack of drug effectiveness. Per the author, Each pharmacogenetic variant may affect the metabolism of several medications used in primary care, in addition to the antidepressant and anti-anxiolytic medications. Given this support, the requested GeneSight genetic testing is indicated for this patient with a history of developmental and behavioral health issues. Moreover, the requested GeneSight genetic testing is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration and not primarily for the convenience of the patient or provider. All told, the requested GeneSight testing 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 clinical genetics and genomics 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 120 units of hyperbaric oxygen therapy (HBOT), press full body chamber. The records provided for review document that this transgender patient underwent a body contouring procedure with grafting of 1100 cc of fat to the flanks and buttocks. Postoperative evaluation two days after the procedure showed normal postoperative healing with swelling, tenderness, and ecchymosis. There was no report of findings indicating compromised healing of the liposuction or the fat grafted areas or threatened or compromised surgical grafts. The patients provider has recommended treatment with HBOT. Fife and colleagues noted that HBOT is ineffective when it is provided to patients who could heal without it. Bassetto and colleagues stated that, HBOT is used on occasion to treat compromised flaps and grafts, where there is decreased perfusion or hypoxia, a practice supported also by the Guidelines from UHMS [Undersea and Hyperbaric Medical Society]. In addition, the authors noted that, HBOT can help maximize the viability of the compromised tissue hereby reducing the need for re-grafting or repeat flap procedures. Overall, there is a lack of peer-reviewed clinical literature documenting the benefit of HBOT in injectable fat grafting. This patient has no evidence of threatened or compromised surgical grafts, and the use of HBOT in injectable fat grafting is not supported by the medical literature. Given these findings, the requested 120 units of HBOT, press full body chamber, is not medically necessary for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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 uvulectomy. On review of this patients records, there is a lack of clinical documentation that other common potential causes of chronic cough, throat clearing, dysphagia, and hoarseness had been ruled out, such as asthma and gastroesophageal reflux disease (GERD). Asthma and GERD are among the most common etiologies of chronic cough. Current medical literature reports do not recommend consideration of modified uvulopalatoplasty until common causes had been ruled out. Additionally, while clinical documentation reported uvular hypertrophy or elongation, there is a lack of evidence that laryngoscopy was performed, which would be helpful in potentially identifying other potential causes of the patients symptoms. Moreover, the records do not indicate that the patients uvula is touching the surface of the epiglottis, which has been shown to trigger cough reflex. For these reasons, the requested uvulectomy is not medically necessary for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 injection in the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of chronic left knee pain since 2018 with evidence of osteoarthritis. The patients condition has not substantially improved despite treatment with exercises and less than two weeks of benefit with corticosteroid injections. In light of the patients worsening pain, the provider has requested treatment with Synvisc One injection into the left knee before considering a total knee arthroplasty. Based on the current peer-reviewed medical literature, the requested Synvisc One injection in the left knee is medically necessary for 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrogel spacer (CPT 55874). This patient presents with a history of prostate cancer. As part of his treatment regimen, the patients providers have recommended use of hydrogel spacers to decrease the toxicity to the rectum while the patient receives proton beam radiation therapy. As noted in the medical literature, hydrogel spacers can be utilized during radiation treatment of the prostate to increase the space between the rectum and prostate and decrease the amount of radiation that is delivered to the rectum (Hamstra, et al.). In a randomized phase 3 study in patients undergoing radiation for prostate cancer, the risk of late adverse events grade 2 or higher, declined from 5.7% to 0% in the control versus hydrogel spacer group. The spacer group also had a significant reduction in bowel quality of life decline. The National Comprehensive Cancer Network (NCCN) guidelines also endorse the use of hydrogel spacers in patients undergoing radiotherapy for prostate cancer. Therefore, requested hydrogel spacer (CPT 55874) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested hydrogel spacer (CPT 55874) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy (28 fraction regimen of 70 Gy high dose). On review of the medical literature, there is a paucity of data demonstrating that treatment with proton therapy is associated with a clinical benefit compared to photon based radiation therapy. Vapiwala and colleagues reported on a recent multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer who were treated with hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. The authors found no significant difference in disease control, or gastrointestinal or genitourinary toxicities between the two treatment modalities. Per the American Society for Radiation Oncology (ASTRO), Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. The ASTRO position statement noted further that the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. Moreover, the National Comprehensive Cancer Network (NCCN) guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity modulated radiation therapy technique. In conclusion, the requested proton beam radiation therapy (28 fraction regimen of 70 Gy high dose) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiation oncology 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 full body magnetic resonance imaging (MRI). Findings:  The physician reviewer found that The arthritis and arthralgias of systemic lupus erythematosus (SLE) are typically nonerosive and generally different from that of rheumatoid arthritis (RA), tending to be migratory, with symptoms in a particular joint that may be gone within 24 hours or last longer. While the arthritis may involve any joint, it is usually symmetric and polyarticular, with a predilection for the knees, carpal joints, and joints of the fingers, especially the proximal interphalangeal (PIP) joint. The ankles, elbows, shoulders, and hips are less frequently involved, and involvement of the sacroiliac joints and cervical spine is rare. While an ultrasound or MRI may reveal chronic synovitis, this would not change the management approach for SLE, nor would it reveal any potential undiagnosed fibromyalgia which may also be contributing to pain in this patient.  Additionally, in this case, as the records note that the patients diagnoses include SLE and class 5 nephritis, any MRI, with contrast, is not indicated due to the risk for contrast nephropathy. Rather, the patients generalized functional pain should be evaluated clinically, and concerns regarding specific organ involvement should be addressed separately and specifically. Given that MRI is not the preferred modality to diagnose and treat generalized polyarthralgia, the requested service is not medically indicated. Therefore, the requested full body MRI is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for in-home international normalized ratio (INR) monitoring device (CPT G0249). The records provided for review document that this patient presents with a history of factor V Leiden, MTHFR, and prothrombin gene mutations. The patient has been treated with anticoagulant therapy since diagnosis with DVT and pulmonary embolism in 2012. The provider has recommended use of an in-home INR monitoring device. As noted in the medical literature, self-monitoring is not feasible for all patients and requires patient education and demonstrated ability to use the device. Phibbs and colleagues reported that in their study of 3,643 patients, 80% of patients were able to demonstrate competency in using an in-home INR monitoring device. In-home INR testing has been shown to be more effective and convenient for patients who require frequent monitoring. Moreover, patient self-testing at home compares favorably with the results achieved in randomized trials or in anticoagulation clinic settings. Given these findings, the requested in-home INR monitoring device (CPT G0249) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for a Flexitouch pneumatic compression device (PCD) and garments. Intermittent pneumatic compression (IPC), also called sequential pneumatic compression, is a method of compression therapy. Blumberg and colleagues report that pneumatic compression is well tolerated by patients and should be recommended as an adjunct to standard lymphedema therapy. Desai and colleagues note that pneumatic compression therapy leads to improved clinical outcomes, quality of life, and functional status for clinically significant lymphedema. In this case, the patient has lymphedema and had failed other therapies. Given that current medical literature supports the use of the requested equipment in this clinical setting, the requested equipment is medically indicated. Therefore, a Flexitouch PCD and garments are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral intercostal nerve radiofrequency ablation (RFA).Findings:  The physician reviewer found that the patients records document a history of intercostal neuralgia. The patient has previously undergone treatment with intercostal nerve RFA with over 50% pain relief, which lasted for six months and is clinically relevant durable pain relief for this condition. There are several small studies demonstrating that RFA of the intercostal nerve can be effective for intercostal neuralgia, as in this patients clinical setting. Ahmed and colleagues reported on a study that evaluated the efficacy of ultrasound guided RFA of the intercostal nerves for patients with rib metastasis. The study included 25 patients with uncontrolled breakthrough pain arising due to rib metastasis. The authors concluded that RFA was associated with more than 50% decrease in both intensity and frequency of breakthrough pain in more than 50% of patients for three months. A case series by Abd-Elsayed and colleagues reviewed two patients with resistant intercostal neuralgia who underwent RFA and reported clinically relevant pain relief for one year. Based on the records provided for review and current published studies, the requested bilateral intercostal nerve RFA is medically necessary for 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right knee (CPT 73721). As noted by Hayashi and colleagues, the best initial imaging examination for the evaluation of chronic knee pain in an adult patient is radiographs. In the setting of osteoarthritis diagnosed by initial radiographs, MRI may be indicated in follow-up if the patients symptoms are not explained by the radiographic findings. According to the American College of Radiology (ACR) recommendations for the evaluation of chronic knee pain in a patient with initial radiographs demonstrating degenerative changes, MRI may be appropriate as the next imaging examination. In this case, despite conservative measures including cortisone injections, the patients chronic knee pain is not explained by the radiographs. Applying the ACR criteria and recommendations from the peer-reviewed medical literature, the next logical step in this patients work-up is MRI (Javaid, et al.). Accordingly, the requested MRI of the right knee (CPT 73721) is medically necessary for evaluation 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 radiology with subspecialty certification in diagnostic radiology 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 magnetic resonance imaging (MRI) of the hand/wrist. While medical literatures note that MRI and ultrasonography are useful tools for evaluating the wrist, researchers report that for the management of De Quervains tenosynovitis, conservative management with splinting, icing, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy are recommended. In a case study of a patient with De Quervains tenosynovitis, researchers noted that conservative care involving NSAIDs and corticosteroid injections as well as occupational therapy to include splinting, activity modification, manual treatment, and therapeutic exercise were initiated. In this case, the patients history and physical examination are most consistent with De Quervains tenosynovitis. Given that conservative measures should first be trialed, the requested service is not medically indicated. Therefore, MRI of the hand/wrist is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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 diagnostic radiology 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.