Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented to the emergency department with a dog bite the day prior. The dog had not been vaccinated for rabies. The patient had pain and puncture wounds to the calf. Dog bites must be emergently evaluated to assess for rabies exposure. Rabies can be prevented with injection of rabies immune globulin. The more timely the administration, the lower the risk of developing rabies. Even though this patient presented the day following the dog bite, rabies immune globulin should not be delayed if rabies exposure is suspected. In addition, dog bite wounds to the extremities should receive antibiotic prophylaxis to prevent infection. The sooner those antibiotics are initiated, the lower the risk of infection. The care provided to this patient in the emergency department meet the criteria for emergency services as defined above. Thus, the services provided were for emergency services.  Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. 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 open magnetic resonance imaging (MRI) for evaluation of the enrollees tendinopathy of the left shoulder. Findings:  The physician reviewer found that the medical literature indicates that MRI is an optimal imaging study to evaluate shoulder anatomy and pathology.  The American College of Radiology has established Appropriateness Criteria (ACR) to evaluate various clinical presentations.  The ACR has established imaging protocols and logarithms to evaluate such entities as low back pain, breast cancer and shoulder pain.  The ACR recommends obtaining plain x-rays as a first line for the evaluation of shoulder pain. However, in their variant 2, it recommends magnetic resonance scanning. The concern in this patients case is whether there are adequate medical indications for an open and presumably lower field strength MRI examination.  The high field strength will produce less patient motion due to shorter scan times. Also, more advanced imaging techniques are available that may not be available on open scanners.  However, in this case, the patient reported extreme claustrophobia.  Therefore, if it is not possible to be scanned on a high field strength magnet, there is support in the literature for using low field strength magnets. Moreover, there are variations in the field strengths in various open magnets available on the market today, ranging from 0.2T to as much as 1.2T.  While it would be preferable to scan this patient on a high field strength magnet, if a surgical intervention is a consideration, then a lower field strength magnet is preferable to no scan at all. As such, the documentation provided as well as the medical evidence support coverage for an open magnetic MRI for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Zepatier 50/100 for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. Findings:  The physician reviewer found that 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 or 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. For these reasons, treatment with Zepatier 50/100 for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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.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 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: The enrollee has requested reimbursement for the Afirma Gene Expression Classifier (GEC) molecular test for evaluation of the enrollees thyroid nodule. Findings:  Two of the physician reviewers found that While a 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 (Alexander, et al). Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority turn out to be benign. Afirma utilizes a GEC in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. All told, the Afirma GEC molecular test provided on 11/29/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that 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 overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for inpatient orthopedic spine surgery (implantation of an endoprosthesis, anterior discectomy and artificial disc placement) for treatment of the enrollees disc herniation and severe degenerative disc disease.  Findings:  The physician reviewer found that the services at issue have not been established as medically necessary for treatment of the patients medical condition. There is a lack of sufficient data to adequately assess the performance of total disc replacements. There is a lack of evidence that disc replacement reliably and reproducibly over long periods of time fulfills the three primary aims of continued motion, clinical efficacy, and fewer adjacent segment degenerative problems. In addition, total disc replacement has been associated with a high rate of future operations, and the potential problems that may occur with longer follow-up have yet to be fully documented. Given the lack of support in the medical literature, the inpatient orthopedic spine surgery (implantation of an endoprosthesis, anterior discectomy and artificial disc placement) was not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in neurological 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: enrollee has requested authorization and coverage for a powered wheelchair with accessories (HCPCS codes K0861 - power wheelchair, group 3 standard, multiple power option, cling/solid seat/back, patient weight capacity up to and including 300 pounds, E1007 - wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction, E2361 - batteries x 2, E2377 - expandable controller, E2313 - harness for expandable controller, E2373 - expandable controller Q-logic, E2331 - attendant control, E2300 - seat elevation, K0108 - transit option, E2311 - multiple actuator, E0978 - lap belt, K0040 - angle adjusted footplates x 2, E0955 - head rest, E0951 - shoe holder x 2, E0952 - padded straps x 2, E2615 - power mounting hardware, and K0955 - seat/back cushion) for treatment of the enrollee, who has cerebral palsy. Findings:  The physician reviewer found that Powered mobility devices can play an important role in maintenance of independence for adults with cerebral palsy.  In this case, the records do not indicate that the patient is able to safely and independently operate a power wheelchair. The patient is specifically reported to be dependent for functional mobility. The records, moreover, indicate that she has intermittent dyskinetic movements of her neck placing it into severe extension.  She has spastic movements of her eyes and arms as well. She has minimal voluntary upper extremity control. These issues, as reported by her examining physician and physical therapist, preclude safe and reliable operation of a power mobility device. There is no documentation related to a power mobility driving trial, with documented abilities to identify obstacles, avoid collisions, and quickly process and react, which are skills required to safely operate a power mobility device.  Proper assessment of safety issues is important to minimize risk.  Overall, there are no indications that a properly fitted manual wheelchair with tilt-in-space and other features to accommodate her posture, tone and pressure relief needs, would not meet the patients needs. A power wheelchair with attendant controls so that it can be operated by a caregiver is a caregiver convenience and not a medical necessity.  All told, the requested equipment is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for applications of Apligraf graft product for treatment of the enrollees unspecified left leg wound due to a dog bite.  Findings:  The physician reviewer found that Apligraf has been shown to be effective in the treatment of chronic venous wounds and wounds associated with surgical excisions (Eaglstein and Falanga). It has also been shown to be effective in diabetic non-healing ulcers (Edmonds, et al). The U.S. Food and Drug Administration (FDA) has approved Apligraf for use in diabetic foot wounds and venous ulcers (Keller). However, the use of Apligraf in patients with a dog bite wound is not clinically indicated or the standard of care. Given the lack of medical literature supporting the services at issue in this clinical setting, the Apligraf graft product was 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 services at issue were 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 reviewer number one is board certified in family medicine with sub-specialty expertise in wound care 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.Physician reviewer number two is board certified in internal medicine with sub-specialty 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.Physician reviewer number three is board certified in internal medicine with sub-specialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for the Cologuard test for evaluation of the enrollees risk of colon cancer. Findings:  The physician reviewer found The Cologuard test performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The documentation submitted for review does not support the testing at issue as more effective than standard colon screening strategies. In addition, the patients reported change in bowel pattern raises concern for colonic pathology that may evade detection by Cologuard. For the reasons provided, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two of three reviewers determined that the testing at issue 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Synvisc One injections for treatment of the enrollees knee pain. The physician reviewer found that there is adequate medical evidence that intraarticular hyaluronic acid injections reduce pain and increase function in patients with knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around two years. In addition, Campbell and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis and found that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. The patient is unable to tolerate NSAIDs, but has benefitted with intraarticular injections of hyaluronic acid in the past. Given this support, the requested Synvisc One injections are medically necessary for treatment of this patients bilateral knee osteoarthritis.  Final Result: The reviewer determined that the requested medication is service 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the Prometheus Anser ADA test for measurement of serum antibodies to adalimumab for evaluation of the enrollees ulcerative colitis. Findings:  The physician reviewer found that Monitoring patients on Humira with measurement of Humira levels and antibodies to Humira continues to be an area of intense investigation. Some data suggests that Humira levels correlate inversely with disease activity. However, there is a lack of controlled data which have identified the optimal drug level. Given the paucity of peer-reviewed medical literature supporting the clinical utility of the Anser ADA test in this circumstance, the Prometheus Anser ADA testing for measurement of serum antibodies to adalimumab performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.