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

An enrollee has requested authorization and coverage for surgical Maze procedure with concomitant endovascular pulmonary vein isolation. The records provided for review document that this patients history of symptomatic and recurrent atrial fibrillation has affected her lifestyle and limited her activity. Prior treatment has included conservative therapy and two prior catheter based ablation procedures. In addition, she is on chronic anticoagulation, and cannot accept blood transfusions due to her religion. Consequently, a minimally invasive approach to treatment would be optimal for this patient. The patients providers have recommended a convergent or hybrid atrial fibrillation ablation procedure along with left atrial appendage removal. There is published data and professional society guidelines that support a hybrid or convergent procedure to isolate the pulmonary veins and posterior left atrium rather than traditional repeat catheter based ablation therapy alone. In addition, due to the specific clinical circumstances for this patient, and contraindication to long-term anticoagulation due to bleeding risk, a concomitant left atrial appendage removal will likely obviate the need for long-term anticoagulation by lessening the embolic stroke risk if there is further recurrent atrial fibrillation. All told, the requested surgical Maze procedure with concomitant endovascular pulmonary vein isolation is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested surgical Maze procedure with concomitant endovascular pulmonary vein isolation is likely to be more beneficial for treatment of the patients 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 internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in cardiovascular disease 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 HP Acthar Gel 80 Units subcutaneously twice per week. The review of the multiple non-biological and non-steroid related therapies found to be effective for the treatment of non-infectious uveitis and did not include Acthar Gel. Similarly, a stepwise approach in terms of immunosuppressive therapies, which did not include Acthar gel. The records provided for review do not document that this patient has active synovitis on current therapy, which includes methotrexate 20 mg weekly. Current medical literature supports methotrexate dosing up to 25 mg weekly and data suggests that the methotrexate might be better absorbed parenterally than orally. The patients ocular disease has not responded to high dose steroids up to 40 mg daily, thus her condition is not likely to respond to Acthar Gel, which also has corticotrophin-related efficacy. The combined toxicity of high dose steroids in addition to Acthar Gel is concerning in terms of risk for glaucoma, hypertension, osteoporosis, osteonecrosis and infection. The patient has not exhausted standard maintenance therapies such as cyclosporine, Imuran, and tacrolimus. The patient is also not receiving maximal dose methotrexate and the CellCept dosing is not stated. This patient requires a standing maintenance therapy and Acthar Gel is not meant to be this type of therapy but rather a bridge therapy until other medications have started to work. It is not an appropriate medical option in this case and has not been adequately studied in patients with bilateral panuveitis in rheumatoid arthritis when the arthritis component of the condition is stable. Based on the current peer-reviewed medical literature, HP Acthar Gel 80 Units subcutaneously twice per week is not medically necessary for treatment of this patient. 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient presents with mild to moderate withdrawal as per CIWA scoring. The patient meets the criterion for dimension 2, the records document bleeding esophageal varices that are fragile and require close medical monitoring. In addition, she has required three intensive care unit (ICU) admissions in the past four years for treatment of substance-related medical complications. Dimension 3 is met, as the patient has comorbid PTSD as well as symptoms of depression and anxiety. For dimension 4, the provider noted that the patient is willing but not yet able or ready for change as evidenced by her reduced ability to attend to activities of daily living. The patient continues to blame external factors. The patient satisfies dimension 5, as she demonstrates impulsive behavior and mood instability as well as varying commitment to treatment. For dimension 6, the patient has shown impulsivity in the context of tending towards social isolation in remote locales. The providers noted that the patient continues to require further monitoring until stabilized, given her tendency to relapse. The patient requires a safe and stable living environment in order to develop her recovery skills and qualifies for ASAM Level III treatment similar to what patient has received at the current facility. Given the severity of the patients illness, the RTC services were and are medically necessary for treatment of this patient. 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 expertise in addiction 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 Actemra. The records provided for review document that this patients diagnoses include end-stage renal disease (ESRD) status post living unrelated renal transplant with persistent donor specific antibodies (DSAs). The patients DSAs have persisted despite prior therapy with rituximab and IVIG. Given this lack of response to rituximab and IVIG, it is unlikely that the patient will respond to retreatment with either of these therapies. Current data has demonstrated the potential benefits of Actemra in this clinical setting. The risk of failing therapy is poor long-term viability of the renal allograft. Therefore, the requested Actemra is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in nephrology 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 prostate artery embolization (PAE) procedures, CPT code 37243 (vascular embolization and occlusion), 36247 (insertion of catheter/abdominal/L-external artery 3rd), and 36248 (insertion of catheter abdominal/L-external artery additional). The first-line therapy for management of benign prostatic hyperplasia (BPH) includes medical therapy. This includes alpha-blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors and anticholinergic medications. The standard of care for management of patients with BPH not responding to medical therapy is transurethral resection of the prostate (TURP). In patients with glands over 100 cc, as this patient, holmium laser enucleation of the prostate (HoLEP) and prostatectomy are recommended. Prostate artery embolization (PAE) is a novel approach for treatment of patients with BPH. Current medical literature on PAE is limited to case series and retrospective comparisons. There is a lack of randomized controlled clinical trials demonstrating the improved efficacy of PAE over TURP, HoLEP or simple prostatectomy. The medical literature does not support use of PAE over standard treatments. All told, the requested PAE procedures, CPT code 37243 (vascular embolization and occlusion), 36247 (insertion of catheter/abdominal/L-external artery 3rd), and 36248 (insertion of catheter abdominal/L-external artery additional) are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested PAE procedures, CPT code 37243 (vascular embolization and occlusion), 36247 (insertion of catheter/abdominal/L-external artery 3rd), and 36248 (insertion of catheter abdominal/L-external artery additional) are 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology 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 has requested authorization and coverage for carpal tunnel surgery. Conservative treatment for carpal tunnel syndrome is preferred for mild and short-term carpal tunnel syndrome. Both surgical and conservative interventions have a role in treating carpal tunnel syndrome. The authors noted that nonsurgical treatment is more effective and safer than surgical treatment, but there was no significant improvement in function, symptoms, or neurophysiological parameters. Overall, nonsurgical treatment is recommended as the optimal choice for carpal tunnel syndrome and surgical release is reserved for patients who have failed conservative treatment. This patient presents with complaints of bilateral hand pain with numbness and tingling primarily in the second through fourth fingers, right greater than left. She has documented functional difficulty with activities involving fine manipulation of the fingers. Clinical examination findings demonstrated intact sensation with positive right Tinels sign. There is electrodiagnostic evidence of mild left and moderate right carpal tunnel syndrome. Conservative treatment has included activity modification, non-steroidal anti-inflammatory drugs (NSAIDs), and a right wrist brace. However, the records do not document a thorough orthopedic evaluation and failure of maximal conservative treatment. Therefore, this requested carpal tunnel syndrome 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vosevi for 24 weeks. McPhee noted that patients with genotype 3 HCV are associated with an increased risk of accelerated liver disease progression. However, the current guidelines for treatment of HCV recommend 12 weeks of therapy. 12 weeks of therapy with sofosbuvir, velpatasvir and voxilaprevir provided high rates of sustained virologic response among patients across HCV genotypes in whom treatment with DAA [direct-acting antiviral agent] regimen had previously failed. Based on the available data, treatment with Vosevi is supported for 12 weeks, not 24 weeks. There is a lack of documentation to demonstrate that a longer course of therapy is needed for this patient. A 12-week course of Vosevi with ribavirin is appropriate therapy for this patient. Therefore, Vosevi for 12 weeks is medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested medication regimen 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 internal medicine with subspecialty certification in infectious disease 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 stress echocardiogram.The submitted documentation supports that the requested services are medically necessary. In this case, the patient has increased coronary risk (hypertension, diabetes, and a family history of premature coronary disease) and symptoms that are concerning for coronary ischemia. The pretest likelihood of obstructive coronary disease in this circumstance is at least intermediate, if not high, such that a stress echocardiogram or nuclear stress test with increased sensitivity and increased specificity compared to treadmill electrocardiography is desirable, even with a normal baseline electrocardiogram. Stress echocardiography is appropriate in this setting and is consistent with appropriateness criteria endorsed by several national organizations. Furthermore, the patient also presents with dyspnea of uncertain cause, and in this setting some evaluation of left ventricular function is appropriate to rule out cardiomyopathy as a cause of dyspnea. Under these circumstances, a stress echocardiogram would simultaneously evaluate both ischemia and left ventricular function. Accordingly, a stress echocardiogram is medically necessary for treatment of the 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 internal medicine, with subspecialty certification in cardiovascular disease, 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 dilation and curettage (D&C). Although this patient initially presented postpartum with evidence of retained products of conception, after administration of Misoprostol the patient no longer had evidence of retained products of conception. An ultrasound performed after the patient underwent treatment with Misoprostol revealed that there were no remaining products of conception. The requested D&C is no longer medically necessary. The patient has no heavy bleeding, fever or pain. Proceeding with a D&C would be more harmful than beneficial. Therefore, the requested D&C without general anesthesia is not medically necessary for the 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 obstetrics and gynecology 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 Entresto. Based on the records provided for review, this patient has congestive heart failure with a mildly reduced ejection fraction of 45%. In the circumstance of a mildly reduced ejection fraction, Entresto has not been demonstrated to improve patient outcomes and is not considered the standard accepted therapy in this setting. Solomon and colleagues reported on the PARAGON-HF trial and compared outcomes with Entresto versus valsartan in patients with heart failure, left ventricle ejection fraction of 45%, and elevated natriuretic peptide levels. The authors found that there were no statistically significant differences identified. Current data suggests that Entresto is indicated for patients with heart failure and an ejection fraction below 40%. Given these findings, the requested Entresto is not medically necessary for treatment of this patient. 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 certification in cardiovascular disease 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

The patients parent has requested authorization and coverage for occupational therapy and assessment with a therapist certified in sensory integration and/or speech therapy. There is a discrepancy between the results of the autism evaluations. However, the evaluation performed by the independent provider included assessment of the patients pragmatic and social language, which do not appear to have been fully assessed in the initial evaluation. Speech therapy to address difficulties with social and pragmatic language is medically necessary for the patient. Medical literature states that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism. Although occupational therapy and a thorough assessment are medically necessary, an assessment with a therapist certified in sensory integration is not medically necessary for the patient, because there is insufficient evidence in the medical literature to support the use of sensory integration based therapy. Sensory integration therapy has been a popular treatment for children with neurodevelopmental disorders but there is significant controversy regarding its effectiveness. The American Academy of Pediatrics states that, parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive. Given the current medical literature and guidelines, an occupational therapy assessment and treatment is with a provider not certified in sensory integration therapy and speech therapy are medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services are 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 neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.