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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hip arthroscopy with labral repair, acetabuloplasty and femoroplasty. Findings:  The physician reviewer found that femoroacetabular impingement results from bony morphologic abnormalities of the hip joint that result in abnormal contact during motion. Patients with femoroacetabular impingement present with chronic, deep, or aching anterior groin pain most commonly in the sitting position, or during or after activity. Patients might also experience occasional sharp pains during activity. Diagnosis of femoroacetabular impingement should be confirmed with radiography. Femoroacetabular impingement can be managed conservatively with rest, modification of activities, medications, and physiotherapy, or with surgical intervention. Recent developments in hip arthroscopy have facilitated a minimally invasive approach to the management of femoroacetabular impingement with few complications. Acetabular labral preservation and repair has been shown to provide superior results when compared with debridement alone.The records provided for review support a diagnosis of femoroacetabular impingement and labral tear. The patient has persistent mechanical symptoms, physical findings of hip tenderness, pain on extremes of motion, and positive anterior hip impingement test. The patients symptoms of chronic aching anterior groin pain are consistent with femoroacetabular impingement. In addition, MRI revealed a labral tear which extends from the 9 oclock to the 3 oclock position, which correlates with the patients known injury. Although she has evidence of osteoarthritis, the provider noted that there is sufficient joint space for a salvage procedure including acetabuloplasty, labral repair, and femoroplasty. Overall, the records establish the patients chronic left hip pain has failed to improve despite adequate conservative treatment including rest, anti-inflammatory medications, physical therapy, and injections. In light of the foregoing, the requested hip arthroscopy with labral repair, acetabuloplasty and femoroplasty is medically necessary for treatment of this patients left hip pain.Final Result: The reviewer determined that the requested surgery 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 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: The patient has requested reimbursement and prospective authorization and coverage for the genetic testing, Next Generation Sequencing (NGS) provided on 12/18/18, and prospective genetic testing, NGS, was and is likely to be more beneficial for evaluation of this patients multiple myeloma than any available standard therapy. Based on the documentation provided for review, Next Generation Sequencing (NGS) was used to monitor this patient with multiple myeloma for minimal residual disease (MRD). As noted by the International Myeloma Working Group (IMWG), monitoring for MRD in patients with multiple myeloma is considered within the current standard of care in evaluating a patients response to therapy. Moreover, the IMWG states that routine monitoring is oftentimes facilitated using NGS. Patients with MRD in the bone marrow after therapy at are higher risk for recurrence and may require additional therapy with closer monitoring. Accordingly, the genetic testing, NGS provided on 12/18/18, and prospective genetic testing, NGS, was and is likely to be more beneficial for evaluation of this patients multiple myeloma than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was and 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:  One reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing.  One Reviewer is board certified in oncology 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 authorization and coverage for laparoscopic anti-reflux surgery utilizing the LINX Reflux Management System (CPT Code 43284). The Health Plan has denied the requested service as investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).Findings:  Three physician reviewers found that Persistent symptoms of heartburn and regurgitation warrant careful monitoring. Ignoring persistent reflux symptoms can lead to severe complications, such as esophageal strictures, Barretts esophagus, and esophageal adenocarcinoma. Consideration of other treatments may become necessary when medical therapy fails to control symptoms. Sphincter augmentation with the LINX Reflux Management System is a surgical option for patients with chronic gastroesophageal disease and an inadequate response to proton pump inhibitors (PPIs). The patient has acid reflux with the predominant symptom of heartburn that was confirmed by a positive wireless pH test and response to a PPI. Other manifestations of acid reflux such as regurgitation or supra-esophageal symptoms including asthma, sinusitis or a cough, are not documented. Lifestyle changes such as weight loss, dietary changes, elevating the head of the bed, and the impact of his symptoms on his quality of life are also not detailed. As such, laparoscopic anti-reflux surgery utilizing the LINX Reflux Management System (CPT Code 43284) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested procedure 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 internal medicine with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether DecisionDx-Melanoma genetic testing (CPT code 84999) performed was likely to have been more beneficial for evaluation of the enrollees condition than any available standard therapy.DecisionDx-Melanoma genetic testing has shown some impressive accuracy in determining risk for metastasis in melanomas. However, the treatment of this patient would not change, based on the results of this examination. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer network (NCCN) guidelines. There is a lack of published data to support its routine use. There is a paucity of literature to support its use in the care of patients with thin melanomas to change health outcomes. There is a lack of current data to determine what to do with the information provided by the test. The patient would still be required to have a wide local excision and follow-up skin surveillance and possible sentinel lymph node biopsy. Final Result: The reviewers determined that the requested test was 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 dermatology, 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: A 30-year-old male has requested authorization and coverage for balloon dilation Eustachian tuboplast for treatment of the enrollees Eustachian tube dysfunction. Findings:  The physician reviewer found that Eustachian tube dysfunction (ETD) is a disorder for which there are limited medical and surgical treatments. Eustachian tube balloon dilation has been shown to be a safe intervention, which may have a positive effect on objective and subjective indicators for chronic dilatory ETD in adult patients. A prospective, multicenter, randomized, controlled study demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter versus continued medical management alone to treat Eustachian tube dilatory dysfunction in adults. Therefore, in this patient with chronic ear disease and ETD, who is status post treatment with tympanostomy tubes and medical therapy, balloon dilation Eustachian tuboplasty (CPT Code 69799) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One physician reviewer found that the literature shows that there are signs of normalization of tympanograms after balloon dilation of the Eustachian tube (ET) but there is no evidence of long-term effects.Final Result: The reviewers determined that the requested procedure 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 otolaryngology 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 an insulin pump and continuous glucose monitor (CGM). Current studies have shown that tight glucose control reduces the risk, delays the onset, and slows the progression of complications. According to the American Diabetes Association (ADA), most adults with type 1 diabetes should be treated with intensive insulin therapy with either multiple daily injections or an insulin pump. Pump therapy can be successfully started at the time of diagnosis and has been shown to be superior in lowering hemoglobin A1C over multiple doses of insulin. Regarding continuous glucose monitor (CGM) devices, the ADA recommends sensor-augmented pump therapy may be considered for adults to improve glycemic control without an increase in hypoglycemia or severe hypoglycemia. The ADA reports that benefits correlate with adherence to ongoing use of the device. Further, an International Consensus on Use of Continuous Glucose Monitoring states that CGM should be considered in conjunction with hemoglobin A1C for glycemic status assessment and therapy adjustment in all patients with type 1 diabetes and patients with type 2 diabetes treated with intensive insulin therapy who are not achieving glucose targets, especially if the patient is experiencing problematic hypoglycemia (Danne, et al). Moreover, the Dexcom CGM recommended by this patients provider is the most effective and efficient management of this patients diabetes type 1. The Dexcom CGM is a real-time monitor that provides immediate feedback, alarms and predictive alarms when glucose levels are trending high or low, allowing the patient to manage her diabetes and prevent dangerous levels of hypoglycemia and hyperglycemia. As a result of improved control, the patient will be at lesser risk for diabetes related complications. Accordingly, the requested insulin pump and CGM are medically necessary for treatment of this patients type 1 diabetes. 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. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a transoral incisionless fundoplication (TIF) procedure utilizing the EsophyX device (CPT code 43210). The Health Plan has denied the requested services as investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  Three physician reviewers found that guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) report that the long-term follow-up data for TIF is limited. These conclusions are bolstered by recent reports of severe adverse events during the procedure and the need for surgery to revise ineffective TIF. As such, the requested TIF procedure utilizing the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: The reviewers determined that the requested procedure 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 internal medicine with subspecialty 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with quadriplegic cerebral palsy. The patient is dependent for all activities of daily living. The patients transfers are with the assistance of a Hoyer lift. He is fed and given medication through a gastrostomy tube. From 1/1/19 through 2/15/19, the patient had 23 seizures. The seizures were described as not involving loss of consciousness and the patient was reported as being alert after the seizures. No rescue medications were administered for seizures, and none are listed in the prescribed medication list. There is no report that the patient has had unstable health or emergency room visits. No pressure-related skin issues were noted. The patient has requested reimbursement and coverage for 40 hours per week of private duty nursing that were provided from 1/1/19 forward. The Health Plan denied the request and reported the services at issue are not medically necessary for the treatment of this patient. At issue in this case is whether the requested 40 hours per week of private duty nursing that were provided from 1/1/19 forward was and is medically necessary for treatment of the patients medical condition. The American Academy of Pediatrics guideline for pediatric home care state that intermittent skilled level of care can be provided by a trained caregiver (McConnell, et al.). Level one medically complex level of care includes ventilator, tracheostomy, recurrent or frequent suctioning, oxygen therapy in connection with apnea monitoring, maintenance of intravenous therapy, nutritional support via continuous nasogastric or gastrostomy tube feeding, or presence of a central intravenous catheter. The patient does not have any of the conditions listed under level one, which would require the provision of a trained nurse. The patient is medically stable. He does not have medical needs requiring skilled nursing care. He is on bolus gastrostomy tube feeds, and has not reportedly experienced regurgitation or aspiration. The patients seizures are brief, and he has not required the administration of rescue medication or emergency room visits. Overall, the medical evidence does not support the services at issue in this clinical setting. Therefore, 40 hours per week of private duty nursing that were provided from 1/1/19 forward was not and is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 pediatrics with a special qualification in child neurology and subspecialty certification in hospice and palliative medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether tongue radiofrequency rendered was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. The patient was diagnosed with chronic rhinosinusitis with nasal obstruction, macroglossia, and obstructive sleep apnea.  The enrollee underwent a partial glossectomy previously.  The enrollee continued to report no improvement in the quality of sleep or symptoms after the procedure. Two out of three medical experts found that per the American Academy of Otolaryngology Head and Neck Surgery (AAOHNS), patients with mild to severe obstructive sleep apnea (OSA) can be successfully treated with submucosal radiofrequency tongue base ablation. Radiofrequency ablation is clinically effective in reducing respiratory disturbance index levels and symptoms of sleepiness in patients with OSA syndrome when directed at the base of the tongue or as a multilevel procedure. Therefore, the tongue radiofrequency that was rendered was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. One out of three reviewers found that this patient has undergone multiple prior surgical procedures, including nasal reconstructive septoplasty, partial glossectomy, and sinus surgery. Currently, there is a lack of literature supporting that tongue based radiofrequency has clinically proven benefit to tighten the tongue after a prior partial glossectomy.Final Result: Two out of three of the reviewers determined that the requested test was 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 otolaryngology, 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 Euflexxa injections in the left knee. The current evidence on viscosupplementation is limited and the guidelines from organizations such as the American Academy of Orthopaedic Surgeons (AAOS) indicate that the data remains inconclusive. As such, the AAOS does not support viscosupplementation as standard treatment for all patients with osteoarthritis of the knees. A review of the medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it has not been established which patients will benefit. However, there is adequate support for viscosupplementation for patients with a history of lasting benefit from prior injections and in carefully selected cases where the treatment options are limited. In this case, the records document the patient has experienced moderate pain relief with prior viscosupplementation. Moreover, prior surgery did not substantially improve his condition and further treatment options are limited to relieve pain and postpone a total knee arthroplasty. As such, the requested Euflexxa injections of the left knee are medically necessary for treatment of this patients knee osteoarthritis. 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.