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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endovenous ablation therapy of incompetent vein (CPT 36475) of the right leg.Findings:  The physician reviewer found that  compression therapy for patients with symptomatic varicose veins, and endovenous thermal ablation for treatment of an incompetent great saphenous vein. In this case, while patient has seen no improvement using compression, the records do not show evidence of bilateral deep vein thrombosis or deep venous insufficiency, and do not describe significant reflux in the vein to be treated. The vein is unremarkable in size. The patient has other health factors, including chronic back pain and morbid obesity, that would hamper appreciable benefit from the requested procedure. The documentation did not reflect lifestyle or mobility limitations due to symptoms from varicose veins. In this clinical setting, the requested procedure is not medically indicated. Therefore, endovenous ablation therapy of incompetent vein (CPT 36475) of the right leg is not medically necessary for the treatment of this patient.Final Result: The reviewer 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 reviewer is board certified in general surgery and in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for insertion of perirectal spacer with SpaceOAR Hydrogel (CPT-55874). In this case, the use of SpaceOAR was standard of care. Karsh and colleagues note that prostate-rectum hydrogel spacer application is a relatively safe technical procedure that is well tolerated and has a high technical success rate. The authors further note that spacer application significantly reduces rectal radiation dose and results in long-term reductions in rectal toxicity, as well as improvements in bowel, urinary, and sexual quality of life. Hamstra and colleagues report that in a single-blind phase III trial of image guided intensity modulated radiation therapy, there was strong evidence for the benefit of hydrogel spacer use in prostate radiation therapy. The National Comprehensive Cancer Network (NCCN) guidelines for management of prostate cancer support the use of SpaceOAR in this clinical setting. Therefore, insertion of perirectal spacer with SpaceOAR Hydrogel (CPT-55874) was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the insertion of perirectal spacer with SpaceOAR Hydrogel (CPT-55874) at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been 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 reviewers 1, 2, and 3 are board certified in radiation 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 authorization and coverage for transoral incisionless fundoplication (TIF). Current medical literature is split on the efficacy of TIF. Sami Trad and colleagues found that TIF appears to be a valuable treatment alternative for the management of appropriately selected patients with moderate to severe chronic gastroesophageal reflux disease (GERD) symptoms, while Witteman and colleagues found that although TIF resulted in an improved GERD-related quality of life and produced a short-term improvement of the antireflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved.  The American Society for Gastrointestinal Endoscopy (ASGE) College of Gastroenterology note that most studies involving TIF have been small with short-term follow-up and that prospective trials comparing these therapies with existing medical and surgical options by using objective measures of GERD as the primary endpoint could be useful in further defining the clinical role of these procedures. Given the uncertainty regarding its long-term efficacy, the requested TIF is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested TIF is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service 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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Orthovisc injection series of the right knee. Findings:  The physician reviewer found that Viscosupplementation or injection of exogenous hyaluronic acid into the knee joint has been studied and found to have limited short-term efficacy in the treatment of osteoarthritic knee pain. There is no scientific evidence indicating hyaluronic acid injection is effective in the treatment of chronic posttraumatic knee pain or improves outcomes following the treatment of multi ligamentous knee injury. As a consequence, no evidence based treatment algorithms recommend hyaluronic acid injection in the clinical scenario of a young patient who has sustained a multi ligamentous knee injury for which surgical ligament reconstruction was performed. In this case, the patient has chronic knee pain following posterior cruciate ligament and posterolateral corner allograft reconstruction. Current medical literature does not support that hyaluronic acid injection would be more effective than standard treatment under these circumstances. Accordingly, the requested Orthovisc injection series of the right knee is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 methylenetetrahydrofolate reductase (MTHFR) gene mutation testing. Papakostas and colleagues conducted two multicenter sequential parallel comparison design trials to investigate the effect of L-methylfolate augmentation in the treatment of major depressive disorder in patients with partial or no response to selective serotonin reuptake inhibitors and concluded that adjunctive L-methylfolate may constitute an effective, safe, and relatively well tolerated treatment strategy. However, the decision to add L-methylfolate to treatment in these trials was not informed by genetic testing and current medical literature does not suggest that genetic testing results in a clinical benefit or is of clinical relevance in the treatment of patients with major depressive disorder. Ravindran and colleagues note that support for the use of folate preparations, particularly L-methylfolate, as monotherapy or adjunct to antidepressants for mild to moderate major depressive disorder is limited by small samples and the lack of double-blind, placebo-controlled trials. Given that treatment decisions to use L-methylfolate are not informed by genetic testing, the service at issue was not standard of care. Therefore, MTHFR gene mutation testing was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the MTHFR gene mutation testing at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 psychiatry 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: An enrollee has requested reimbursement for hospitalization services.The submitted documentation supports that the services at issue were medically necessary. Atypical symptoms of ischemia can be the presenting signs of an acute coronary syndrome in women (Jones, E., et al.). Diabetes mellitus is a significant cause of death and disability worldwide and is a strong risk factor for acute coronary syndrome (ACS). The excess risk of ACS associated with diabetes is significantly higher in women than in men (Dong, X., et al.). In this case, the patient has a history of diabetes and presented with both typical and atypical symptoms of ischemia. The patient also had an abnormal electrocardiogram (EKG) and was appropriately admitted for a possible acute coronary syndrome. After the patient was ruled out of myocardial infarction (MI), a stress test was done that was negative for ischemia, and telemetry monitoring revealed paroxysmal atrial fibrillation that correlated with the patients symptoms. Based on the patients presenting complaints, her elevated pre-test probability of coronary artery disease (CAD) due to age and diabetes, and her abnormal baseline EKG, her inpatient hospital admission and the guideline directed medical therapy and evaluation that she received for unstable ischemic heart disease (which was eventually ruled out) was medically necessary and appropriate. The patients diabetes also put her at increased risk for a poor outcome if this had been an ischemic syndrome. Under these circumstances, the hospitalization services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat 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 additional physical therapy. Researchers note that management of adhesive capsulitis is based on the underlying cause of pain and stiffness, and determination of the etiology is essential. The authors further note that management of true capsular restriction of motion begins with gentle, progressive stretching exercises. While range of motion programs may be started in a formal setting by physical therapists, they can be transitioned to an independent program over time and frequent range of motion exercise in the home setting may play a larger role in effectuating positive outcomes than in a formal therapy setting. Researchers note that interventions such as steroid injections or other analgesic measures can be considered during the painful stages of initiating mobilization to expedite recovery. In this case, the patient has neck pain radiating down the right arm and shoulder with limited range of motion in the right arm, and has been diagnosed with full thickness right rotator cuff tears. In this clinical setting, the limited active right shoulder range of motion is not rectifiable by physical therapy due to the underlying rotator cuff pathology. The documentation reports that the patient has already undergone physical therapy without significant benefit. Given that the records do not support that continued formal therapy would confer a meaningful benefit to the patient in this clinical setting, the requested services are not medically indicated. Therefore, additional physical therapy 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 physical medicine and rehabilitation 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 physical therapy with a Certified Functional Manual Therapist. Ehlers-Danlos syndromes are characterized by joint hypermobility, chronic severe pains, and fatigue. In addition to pain related to mechanical factors at the affected joints, a generalized hyperalgesia has been described that may be due to a sensitized central nervous system, implying underlying pain mechanisms similar to fibromyalgia. Rehabilitation aims to reduce disability and improve quality of life. The evidence related to the effectiveness of specific treatments for reducing disability in this patient population is limited. Therapy interventions such as manual therapy, taping, hydrotherapy, and relaxation training are frequently employed. However, there is a lack of high-grade evidence demonstrating the clinical benefits in the setting of the heritable hypermobility syndromes. Based on current data, specialized clinical training and additional certification in manual therapy over the manual therapy utilized by licensed physical therapists has not yielded superior health outcomes. In the present case, the patient reportedly developed severe back pain following a treatment aimed at the sacroiliac joint in July 2020. The evidence-based literature does not support that the proposed intervention by a therapist certified in manual therapy will effectuate a favorable impact on the patients clinical course or outcomes beyond standard physical therapy. Therefore, the requested physical therapy with a Certified Functional Manual Therapist 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 physical medicine and rehabilitation 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 patients parent has requested authorization and coverage for Dupixent 200 mg syringe every two weeks. A study describes atopic dermatitis as a common chronic inflammatory skin disease, typically starting in infancy, with increased risk for subsequent extracutaneous atopic morbidities. The U.S. Food and Drug Administration (FDA) approves the use of Dupixent (generic name dupilumab) for the treatment of patients aged 12 years and older with moderate to severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. A systemic literature review concluded for severe atopic dermatitis refractory to topical therapies, the strongest evidence currently existed for dupilumab and cyclosporine at improving clinical disease severity. Another study noted as a strategy to minimize atopic dermatitis flares during the COVID-19 pandemic, for patients with moderate to severe atopic dermatitis whose disease required a new systemic agent, starting dupilumab may be preferable to starting a traditional immunosuppressant during this time. In this case, the patient has severe atopic dermatitis and has tried and failed multiple topical corticosteroids, oral antihistamines, prescription moisturizers and topical anti-infective agents. In this clinical setting, the requested medication is medically indicated. Therefore, Dupixent 200 mg syringe every two weeks is medically necessary to prevent disease, disability, and other health conditions or their progression.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 dermatology 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 patients parent has requested authorization and coverage for Dupixent. A study describes atopic dermatitis as a common, chronic inflammatory skin disease, typically starting in infancy, with increased risk for subsequent extracutaneous atopic morbidities. The U.S. Food and Drug Administration (FDA) approves the use of Dupixent (generic name dupilumab) for the treatment of patients aged 12 years and older with moderate to severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. A systemic literature review concluded that for severe atopic dermatitis refractory to topical therapies, the strongest evidence currently existed for dupilumab and cyclosporine at improving clinical disease severity. Another study noted that as a strategy to minimize atopic dermatitis flares during the COVID-19 pandemic, for patients with moderate to severe atopic dermatitis whose disease required a new systemic agent, starting dupilumab may be preferable to starting a traditional immunosuppressant during this time. In this case, the patient has severe atopic dermatitis and has tried and failed multiple topical corticosteroids, oral antihistamines, prescription moisturizers and topical anti-infective agents. In this clinical setting, the requested medication is medically indicated. Therefore, Dupixent is medically necessary for the 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 dermatology 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 Xenon-enhanced computed tomography (CT) cerebral blood flow study. The International Headache Society (IHS) defines post-traumatic headache as a secondary headache attributed to trauma or injury to the head that develops within seven days following the trauma. Acute post-traumatic headache is defined when the headache resolves within three months after traumatic brain injury (TBI), whereas persistent post-traumatic headache is characterized by headache lasting longer than three months. Patients with a history of TBI and new headache complaints require additional imaging to rule out other causes. Any acute change in neurologic status or sudden change in frequency and intensity of headache may also warrant additional imaging. Xenon-enhanced CT reveals blood flow to various regions of the brain. Xenon-enhanced CT has been shown to have utility in occlusive vascular disease, ischemic and hemorrhagic stroke, subarachnoid hemorrhage, trauma, hydrocephalus, epilepsy, and tumor. In this case, the patient presents with post-traumatic headaches. The current studies and recommendations have not demonstrated the utility of Xenon-enhanced CT cerebral blood flow study in the work-up of patients with post-traumatic headaches. Accordingly, the requested Xenon-enhanced CT cerebral blood flow study is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Xenon-enhanced CT cerebral blood flow study is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 reviewer 1 is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 3 is board certified in neurology 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.