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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a heart monitor. On the basis of the current data, exercise testing, alone or with an imaging study, remains the preferred test for risk stratification of patients with coronary artery disease. For patients who cannot perform exercise, ambulatory electrocardiography (ECG) can be used for further evaluation. The American College of Cardiology (ACC) and American Heart Association (AHA) indications for ambulatory ECG monitoring for myocardial ischemia include suspected variant angina and evaluation of patients with chest pain who cannot exercise. This patient meets these criteria with suspected variant angina and inability to complete an exercise stress test. Ambulatory ECG has been used for preoperative evaluation of patients with peripheral vascular disease with no clinical evidence of coronary artery disease. Given this patients chest pain and history, the heart monitor was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Helicobacter Pylori lab testing. Findings: Two of the three physician reviewers found that Helicobacter Pylori lab testing was not indicated under these circumstances. A recent study of the diagnosis of Helicobacter Pylori infection by researchers noted that the urea breath test or the stool antigen test can be used for non-invasive screening for Helicobacter Pylori in a test and treat strategy in younger patients presenting with dyspepsia without alarm symptoms. Serologic testing was not recommended, however, as it cannot distinguish between active disease and previous exposure. Antibodies to H pylori can remain elevated for a long time even after treatment, potentially increasing the number of false-positive results and thus unnecessary antibiotic exposure. Therefore, the services in issue were 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 in 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:  One reviewer is board certified in internal medicine, with subspecialty certification in gastroenterology, and is actively practicing. One Reviewer is board certified in internal medicine, with subspecialty certification in gastroenterology, and is actively practicing. One Reviewer is board certified in gastroenterology, 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: An enrollee has requested authorization and coverage for Saxenda. Recent literature explains that few medications are currently available for the treatment of obesity, and their effectiveness and benefits often fade when the drugs are stopped. Researchers explain that Saxenda (liraglutide) is a glucagon-like peptide 1 (GLP-1) receptor agonist that shares 97% homology to native GLP-1 and it has demonstrated a statistically significant and clinically meaningful weight loss as an adjunct to a reduced-calorie diet and increased physical activity. As such, researchers noted that data has demonstrated that patients using Saxenda can successfully achieve weight-loss benchmarks of 5% or more and 10% or more loss from baseline. By using Saxenda, this patient will hopefully be able to lose a significant amount of weight and thereby decrease the patients likelihood of progression from prediabetes toward diabetes in the future. Therefore, the requested Saxenda is medically necessary for treatment of this patients condition. Final Result: The physician reviewer determined that the requested medication is medically necessary for treatment of the enrollees condition.Credentials/Qualifications: The physician reviewer is board certified in 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: An enrollee has requested authorization and coverage for Supartz injections for both knees. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Current literature states there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. Campbell and colleagues performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Supartz injections of the knees are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a vacuum erection system. The submitted documentation supports the medical necessity of the requested device. There are multiple options for the treatment of erectile dysfunction. Oral medication is the typical first-line therapy. Vacuum erection devices, intraurethral suppositories and intracavernous injections are second-line therapies for the treatment of patients who are refractory to oral medications. This patient has failed oral therapy. As such, the requested device is medically appropriate for the management of this patients erectile dysfunction. Therefore, the requested vacuum erection system is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 urology 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 parent of a four-year-old male enrollee has requested reimbursement and prospective authorization and coverage for social skills group therapy and group speech therapy services. Findings:  The physician reviewer found that based on the available documentation, the social skills group therapy and group speech therapy services provided were not and are not medically necessary for treatment of this patients medical condition. The National Autism Center highlights ABA therapy as the most effective evidence-based treatment for autism. In this case, the patient is currently accessing medically necessary treatment in the form of ABA therapy, which has led to a decrease in overall autism symptoms. While the patient still has specific areas of concern, his ABA provider has outlined goals to focus on the patients specific deficits. Further, the patients speech and language assessment from 3/12/18 indicated that the patient should wait until five years of age for social skills group, and social goals should continue to be addressed through ABA services. All told, the social skills group therapy and group speech therapy services provided were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 psychology and is a board certified behavioral analyst 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 a referral to a plastic surgeon for breast reduction surgery and breast reduction surgery. Findings:  The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the requested referral to a plastic surgeon for breast reduction surgery. The medical documentation provided is limited, and photographs were not provided for review. In order to demonstrate the medical necessity of a consultation for breast reduction, the records should indicate a functional impairment related to enlarged breast size. However, there is a lack of documentation from the primary care provider to support the stated diagnosis of macromastia. There has not been documentation of a breast examination. Based on the medical documentation provided for review, the requested referral to a plastic surgeon for breast reduction surgery is not medically necessary for the treatment of this patient.In this patients case, the records do not document a functional impairment related to enlarged breast size. Thus, based on the medical documentation provided for this review, breast reduction surgery is not medically necessary. Macromastia is considered an abnormal hypertrophy of breast tissue. This can be considered a developmental abnormality. However, the medical documentation does not support a functional impairment in this patients case. Additionally, it cannot be determined that the requested surgery will create a normal appearance to the extent possible, as the severity of any abnormal appearance cannot be determined due to the lack of photographs. Thus, the records do not establish that the surgery will provide more than a minimal improvement in the appearance of the patient. Therefore, the requested breast reduction surgery is not medically necessary and is not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. While the patient does not meet the criteria for autism, his medical condition meets the criteria for treatment with ABA. The current medical literature suggests that ABA is an effective treatment for patients with ADHD, intellectual disability, and aggressive behavior disorder. Colleagues conducted a meta-analysis on the effect of behavioral treatment on patients with ADHD. Treatments included parent based, teacher based, and child based strategies utilizing operant contingencies and antecedent manipulation. The authors found that behavioral treatments improve the functioning of children with ADHD. In addition, colleagues described the outcomes of 52 patients who underwent behavioral assessment and treatment in the outpatient setting. Of the patients evaluated, 35 had an intellectual disability, and nine were diagnosed with ADHD. The authors reported that in their study, behavior intervention yielded a 96% reduction in problem behavior compared to baseline. Considering this patients history of ADHD, intellectual disability and aggressive behavior disorder, his behavioral issues are likely to improve with ABA therapy. As the patients records do not include a current evaluation for behavioral consultation services, a thorough evaluation is indicated to assist in determining the frequency of ABA therapy that is appropriate. All told, the requested ABA therapy is medically necessary for treatment of this patients medical condition. 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 psychology and is a board certified behavior analyst 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 authorization and coverage for Prometheus Anser IFX testing. Findings:  Three physician reviewers found the presence of antibodies alone does not necessarily result in reactions to infliximab or loss of response to infliximab, nor have threshold levels been established. Furthermore, 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 reports contradictory outcomes and 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 this testing improves outcome. For these reasons, the superior effectiveness of Prometheus Anser IFX testing has not been established. Final Result: The reviewers determined that the requested services are 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 gastroenterology 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 reimbursement for the gene test. According to medical research, given the performance of conventional screening methods, the limitations of cell free DNA screening performance and the limited data on cost effectiveness in the low risk obstetrical population, conventional screening methods remain the most appropriate choice for first-line screening for most women in the general obstetric population. However, this patient has a history of high risk pregnancy due to advanced maternal age. Thus, cell free DNA screen was indicated. Despite the support for cell free DNA in this clinical setting, the fetal sex determination and chromosomal microarray analysis were not likely to provide additional beneficial data. Testing for these genetic disorders is usually directed at patients with a specific family history or ethnicity. Review of this patients chart does not document any such risk factors. Given these findings, the cell free DNA portion of the gene test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the chromosomal microarray and fetal sex determination portions of the testing were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that Final Result: Two of the three reviewers determined that a portion of 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 partially overturned.Credentials/Qualifications:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology 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: An enrollee has requested reimbursement for insertion of presbyopia correcting intraocular lenses (V2788) after cataract surgery and the use of a laser (ZCAT) to assist with performing the cataract surgery. The submitted documentation fails to demonstrate the medical necessity of the services at issue. Findings: Femtolaser assisted cataract surgery (FLACS) and presbyopia correcting intraocular lenses are not considered a medical necessity in standard cataract surgery. Femtolaser has been utilized in different aspects of cataract surgery such as creation of incisions, arucate keratotomies, and anterior capsulorrhexis and nuclear fragmentation.  Studies have indicated that FLACS does not carry additional risk compared to non-FLACS small incision phacoemulsification cataract surgery. Currently, there is not sufficient evidence that FLACS offers better outcomes than non-FLACS small incision phacoemulsification cataract surgery for standard cases with a basic monofocal IOL.  Presbyopia correcting lenses are offered to patients as an out-of-pocket expense to provide less spectacle dependence for intermediate and near vision. Monofocal lenses provide excellent outcomes for single vision correction (distance or near) and are considered the standard of care. Therefore, the insertion of presbyopia correcting intraocular lenses after cataract surgery and the use of a laser to assist with performing the cataract surgery were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 ophthalmology 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 Xeljanz. Xeljanz is U.S. Food and Drug Administration (FDA) approved for the treatment of ulcerative colitis. As noted in the medical literature, Xeljanz has a different mechanism of action than aminosalicylate immunomodulators, anti-TNF therapies, and Entyvio. Xeljanz has been demonstrated to be effective in a double-blind, placebo-controlled trial of patients with moderate-to-severe ulcerative colitis, with up to 78% clinical response and 41% clinical remission at eight weeks. The current medical literature supports Xeljanz as medically necessary for treatment of this patients ulcerative colitis. This patient has failed multiple standard therapies. Specifically, the patient did not improve with anti-tumor necrosis factor (TNF) agent Remicade or high-dose Entyvio. Thus, treatment with another anti-TNF agent, Humira, is likely to be ineffective. All told, Xeljanz is supported as medically necessary for the treatment of this patients ulcerative colitis.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 gastroenterology 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.