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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy for treatment of a symptomatic abdominal pannus as a result of significant weight loss.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for the requested procedure in this clinical setting. This patient had undergone significant weight loss following bariatric surgery.  She has evidence of a symptomatic abdominal pannus as a result of her significant weight loss.  Her symptoms have included chronic rashes and back pain.  She has attempted typical dermatologic treatment, which has not been able to control her rashes and boils.  The submitted photographs support her clinical scenario of functional impairment related to the pannus. There is evidence of a severe lower abdominal pannus that hangs below the pubic bone. In this patients case, there is sufficient detail in the medical documentation to support that there are functional problems related to her lower abdominal overhang. She has chronic rashes that have failed to resolve with typical dermatologic treatment.  Therefore, the requested panniculectomy is medically necessary for treatment of this patients medical condition.  In this patients case, the lower abdominal overhang is an abnormal occurrence, because of the previous weight loss. The weight loss was the cause of the abnormal presentation. The requested panniculectomy will relieve her functional problems from chronic rashes and back pain. Accordingly, panniculectomy would be expected to provide more than a minimal improvement in the appearance of this patient. As such, the requested panniculectomy is reconstructive in nature. Final Result: The reviewer determined that the requested procedure is medically necessary and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: an enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine (CPT code 72148 MRI, spinal canal and contents, lumbar, without contrast). Findings:  The physician reviewer found that medical literature supports obtaining an imaging study when it will change the course of therapy.  The correlation between magnetic resonance findings and clinical symptoms require strict clinical correlation. The American College of Radiology (ACR) has established appropriateness criteria to evaluate various clinical presentations, including low back pain.  The guidelines indicate that imaging patients with acute low back pain of less than six weeks duration and no red flag symptoms provide no clinical benefit (ACR Appropriateness Criteria). The ACR also notes, [I]nterestingly, the size and type of disc herniation and location and presence of nerve root compression were not related to patient outcome. A recent study found no statistically significant difference in primary outcome after 1 year for older adults who had spine imaging within 6 weeks after an initial visit for care for LBP versus similar patients who did not undergo early imaging. It is well documented that imaging patients with chronic LBP is often not beneficial and similar imaging findings are often present in asymptomatic individuals. Additionally, patients with new episodes of LBP and previous MRI scans are unlikely to detect changes in disc protrusion, annular fissures, high-intensity zones, or end-plate signal changes with repeated MRI. In this clinical setting, routine radiographs, while generally obtained, are not helpful.   Moreover, conservative management for this patient has not been documented. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: enrollee has requested authorization and coverage for cervical/thoracic facet joint block. Findings:  The physician reviewer found that the patient underwent a negative diagnostic medial branch block procedure on the left side. Sedation is not appropriate when performing the proposed procedure as a patient needs to be able to communicate during the procedure to avoid potential needle misplacement which could have adverse results. Additionally, there is no evidence the patient has failed conservative treatments such as physical therapy, chiropractic care, or medications. Final Result: The reviewers determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: the physician reviewer is board certified in physical medicine and rehabilitation with sub-specialty 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: An enrollee has requested reimbursement for Aranesp 200 mcg provided retrospectively and and prospective authorization and coverage for Aranesp 200 mcg, every four weeks or as needed for hemoglobin (Hgb) less than 10 for treatment of her anemia secondary to chronic kidney failure. Findings:  The physician reviewer found that the medication at issue is partially indicated in this clinical setting. This patient is diagnosed with anemia, secondary to chronic kidney disease and is not on dialysis. Accordingly, the appropriate dose is .45 mcg/Kg (body weight), every four weeks, to be adjusted up if needed as stated in the prescribing information of the medication guideline. Both Procrit and Aranesp may be used for treatment of this patients medical condition. While both medications carry warning labels for patients diagnosed with hypertension, the provider and the patient have reported debilitating side effects when the patient trialed Procrit. As such, Aranesp appears to better tolerated by this patient. Therefore, Aranesp is clinically supported because of the side effects the patient experiences with Procrit but at the dose of .45 mcg/Kg (body weight), every four weeks and not the stated dose of 200 mcg every two weeks or four weeks. For these reasons, a portion of the medication at issue was and is medically necessary. Specifically, Aranesp 45 mcg/Kg (body weight), as recommended in the prescribing information guide is medically necessary for treatment of this patient. Final Result: The reviewer determined that that a portion of the medication at issue was and 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 sub-specialty certification in hematology and medical 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested hospital services on an emergent basis. Findings:  The physician reviewer found that The services at issue were not necessary for treatment of an emergency medical condition. In this case, the patient presented to the emergency department. At that time, her pain had been present of over one week. Her pain was rated as moderate. The patient denied any systemic or neurologic symptoms. Her ear drainage had resolved but the patient had residual erythema of her tympanic membrane. She was prescribed oral antibiotics. The patient presented two weeks later to the emergency department, with reports of persistent ear pain. Her pain had been relieved with over-the-counter pain medication. The patient denied any systemic or neurologic symptoms. Given that the patients symptoms were not acute or sudden, the services at issue were not necessary for treatment of an emergency medical condition. Final Result: The reviewers determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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: An enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of her chronic hepatitis C virus genotype 1a. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing performed. Findings:  The physician reviewer found that The patient was diagnosed with a common shoulder strain, and her treatment plan was for symptomatic management with anti-inflammatory medications such as Motrin. There are tests which can specify an individual patients genetic type with respect to the metabolism of different drugs, including opioids and nonsteroidal anti-inflammatory drugs. However, there is no evidence that these tests provide clinical benefit, except in very specific circumstances such as the use of clopidogrel, which was not an issue with this patient. There is a lack of support for the services at issue in the routine management of a musculoskeletal condition.  In sum, the superior effectiveness of panel of gene tests received has not been established. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1, 2 and 3 are board certified in internal medicine 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: An enrollee has requested reimbursement for allergy testing laboratory services performed . Findings: The physician reviewer found that : there is a lack of support for the services at issue in this patients case.  Testing of food-specific IgG/IgA levels does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance.  Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods.  Researchers  performed a study of children with atopic dermatitis and egg and/or milk allergy.  The authors noted that those who had higher levels of IgG4 to milk and egg proteins were more likely to tolerate these foods by 4.5 years of age compared with children with lower IgG4 levels. Per the medical evidence, food-specific IgG should not be used as a tool to diagnose food allergy, and the positive food should not be eliminated from the diet based upon results of these tests. The standard evaluation of food allergy consists of blood IgE level for foods and skin testing.  Immunoglobulin E (IgE) immunoassays are in vitro assays used to identify food-specific IgE in the serum. These tests are widely available and have demonstrated very high positive predictive accuracy for several of the major food allergens. Values have been established for egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95 percent. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food.  A negative skin test result indicates the absence of an IgE-mediated allergy upon subsequent challenge with a 90 to 95 percent predictive accuracy. All told, allergy testing laboratory services performed were not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer is board certified in allergy and immunology 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 Harvoni 90-400 mg tablets for 12 weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic genotype 1 patients who have failed PEG-interferon/ribavirin and triple therapy should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks, based on clinical trials in this population . In genotype 1a patients without NS5A resistance, as in this case, Zepatier for 12 weeks is appropriate. The guidelines recommend either Harvoni or Zepatier as acceptable therapy. No medical contraindication to Zepatier is reported in this case. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, treatment of hepatitis C is needed, but the requested treatment with Harvoni 90-400 mg tablets for 12 weeks is not medically necessary for the treatment of this patients hepatitis C infection given the availability of Zepatier. 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 gene testing provided on dates A, B & C.  Findings:  The physician reviewer found that the Guardant360 gene testing provided on date A and C were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the medical literature supporting the use of liquid biopsy to guide a patients therapeutic plan in addition to standard of care practices such as clinical, laboratory, and radiographic evaluations. However, there is a lack of documentation supporting the gene testing performed on date B. The records do not support rationale as to the role of the repeat Guardant360 gene testing performed one month after the initial test. In sum, the testing performed on date A and date C were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that a portion of the testing at issue 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 partially overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: An enrollee has requested reimbursement for genetic testing called ThyGenX.  Findings:  Three physician reviewers found that fine needle aspiration (FNA) biopsy yielded cytology which was consistent with papillary thyroid carcinoma (Bethesda Category VI). A specimen was subsequently sent for ThyGenX molecular analysis. While an FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, studies have shown that the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The relatively new development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. Among these tests is ThyGenX, which analyzes a panel of DNA mutations and RNA translocation fusion markers to assess the risk of malignancy with good negative and positive predictive value, obviating the need for unnecessary surgeries. ThyGenX has emerged as a promising method for clarifying the gray area of indeterminate thyroid FNAs.  However, in the case of this patient, her initial cytology was not indeterminate. The nodule was consistent with papillary thyroid carcinoma. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: 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 LINX Reflux Management System for treatment of the her gastroesophageal reflux disease (GERD).  Findings:  Three physician reviewers found that The peer-reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial in this case than standard treatment. There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. Additionally, LINX is associated with severe dysphagia requiring endoscopic intervention. The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Final Result: The reviewers determined that the requested surgery is 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: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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.