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 a consultation with an orthopedic surgeon who specializes in hand and wrist surgery in adults for evaluation of the enrollees chronic bilateral wrist pain.Findings: The physician reviewer found that evidence based medical peer reviewed literature recommends surgical consultation for patients who fail to respond to nonsurgical management or have clear clinical and special study evidence of a lesion that has been shown to benefit, in both the short and long term, from surgical intervention. Current evidence based peer reviewed literature supports decision aids in the orthopedic treatment of patients, utilizing appropriate levels of care for initial evaluation and treatment. This patient presents with worsening bilateral wrist pain and hand numbness. Significant impairment is reported in activities of daily living and work ability. Signs and symptoms, clinical examination findings, and imaging are noted and are consistent with carpal tunnel syndrome. Records documented conservative treatment to include anti-inflammatory medications, activity modification, and wrist splinting. He had been under treatment with an orthopedic surgeon in September 2017 who had recommended treatment to include injection therapy and electrodiagnostic studies, which have not been completed. Current evidence based medical guidelines and literature support specialty referrals for this patient based on persistent and worsening symptoms and documented failure of conservative treatment. Therefore, a referral to an orthopedic surgeon who specializes in hand and wrist surgery in adults is medically necessary 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal fusion at L5-S1 for treatment of the enrollees L5-S1 annular tear with severe degenerative disc disease. Findings:  The physician reviewer found that as noted, lumbar fusion is a commonly performed procedure for the treatment of painful instability of the spine, usually manifest as chronic low back pain. This patients medical records show that the patient has degenerative back pain and disc degeneration. However, there is no evidence of lumbar instability, fracture, or tumor. Moreover, the patient has not reportedly failed conservative treatment. Thus, the established criteria for lumbar fusion have not been met. Accordingly, the requested lumbar spinal fusion at L5-S1 is not medically necessary for treatment of this patients back pain. Final Result: The reviewer determined that the requested surgery 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 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 patient has requested reimbursement for the Prevena negative pressure wound therapy placed on 6/19/17 for treatment of the enrollees breast reconstruction. Findings:  The physician reviewer found that This patient had a fresh dry surgical wound following breast implant placement in breast reconstruction. There is no report of obesity, diabetes, drainage, infection, or conditional negatively affecting wound healing. The current peer-reviewed medical literature on the use of the Prevena negative pressure wound management device present case reports or small series reports without controls. No randomized control trials could be found for review. Gorgulu noted that negative pressure wound therapy is routinely utilized in plastic surgery for the treatment of open wounds. However, a newer system, known as closed-incision management (CIM), may minimize the likelihood of open wounds. CIM is designed for use after primary surgical skin closure. The authors reported on a 2 cm area of superficial skin necrosis that followed the use of the Prevena device in an abdominoplasty. Overall, the published articles do not document that the use of the Prevena negative pressure wound management device placed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the device 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation treatments for treatment of the enrollee who has a history of neurogenic bladder and urinary incontinence. Findings: The physician reviewer found that there is a lack of support in the literature for the superior efficacy of the services at issue. In most cases of overactive bladder, behavioral treatment is considered as first line therapy. Antimuscarinic drugs alone or in combination with intermittent self -catheterization, are currently the mainstay of conservative treatment. Several other medications may help in specific disease conditions. Second line treatment includes botulinum toxin A injection and indwelling catheters. Third line of therapy for selected patients include neuromodulation and surgery. Percutaneous tibial nerve stimulation may also be indicated when standard conservative therapies have been tried and failed. In this patients case, the records do not reflect that she has been treated with first and second line therapies. Therefore, percutaneous tibial nerve stimulation treatments were not and are not likely to be of greater benefit than the standard therapies for the treatment of this patients medical condition. Final Result: The reviewers determined that the services at issue were not and 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: All three physician reviewers 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the FoundationOne gene test for evaluation of the enrollees thymic carcinoma.  Findings: Three physician reviewers found that the FoundationOne gene testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to Lamarca and colleagues Thymic malignancies are extremely rare although usually affect young adults and continue to remain an important health problem. Like other rare diseases, progress in thymic malignancies has been slow and the treatment cornerstone still remains surgical resection. Next generation sequencing and other advances in molecular biology are shedding light onto the multiple genetic aberrations involved and have opened a new field for research with molecularly targeted therapies such as CKIT inhibitors or anti-EGFR therapies. A study by Von Hoff and colleagues of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to where the progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has significant results for patients with stage IV tumors and results from molecular profiling offer a rational selection of the next regimen. Therefore, the testing at issue 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: All three physician reviewers 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a cortisone injection for treatment of the enrollees inguinodynia. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation supports the medical necessity of the requested services. There is no contraindication to performing a steroid injection prior to surgery. The medical evidence supports performing the injection using ultrasound guidance to assure precision placement. Colleagues have suggested a stepwise approach which includes steroid injections. A steroid injection does not preclude surgery. There is no indication that surgery should be delayed after steroid injection. The medical evidence supports the requested services in this clinical setting. All told, the requested cortisone injection is medically necessary for the treatment of this patient. 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 anesthesiology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic test (Afirma Gene Expression Classifier) for evaluation of the enrollees indeterminate thyroid nodule. Findings:  The physician reviewer found that While a fine needle aspiration (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 indeterminate. Until recently, studies have shown that the only way to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma Gene Expression Classifier test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is suggestive of a benign nodule and can therefore preclude such surgical procedures. For the reasons stated above, Afirma Gene Expression Classifier was likely to have been more beneficial for the evaluation of this patient than any available standard therapy. Final Result: Two of three reviewers determined that the services at issue were 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Fetal Congen AB (gene panel) testing for evaluation of the enrollees pregnancy at advanced maternal age.  Findings:  Two physician reviewers found that according to the American College of Obstetricians and Gynecologists (ACOG) committee opinion for carrier screening for genetic conditions, recommendations have been made for specific conditions. The specific conditions include: screening for spinal muscular atrophy, which is recommended to be offered to all women who are considering pregnancy or are currently pregnant; Cystic fibrosis carrier screening is recommended be offered to all women who are considering pregnancy or are currently pregnant; and fragile X premutation carrier screening is recommended for women with a family history of fragile X-related disorders or intellectual disability suggestive of fragile X syndrome and who are considering pregnancy or are currently pregnant. Thus, current ACOG recommendations support testing for spinal muscular atrophy and cystic fibrosis carrier screening. However, fragile X is not recommended for all women. For the reasons provided, a portion of the fetal Congen AB (gene panel) testing performed that included screening for muscular atrophy and cystic fibrosis was 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: Reviewer 1 is board certified in obstetrics and gynecology with sub-specialty certification in maternal and fetal medicine and is actively practicing. Reviewer 2 and 3 are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for human growth hormone (GH) (Nutropin AQ Nuspin 10 mg/2 mL (5 mg/mL)) pen injector for treatment of the enrollees short stature.Findings:  The physician reviewer found that This patients height is more than two standard deviations (SDs) delayed, his growth velocity is poor, and his adult predicted height is just below 63 inches, which is shorter than expected for the genetic potential and  more than two SDs below the mean for his gender. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than two SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets most of the above criteria, and his adult predicted height of less than 63 inches is short enough to warrant a trial of GH therapy based on current U.S. Food and Drug Administration (FDA) standards for treatment of idiopathic short stature. All told, the requested human GH (Nutropin AQ Nuspin 10 mg/2 mL (5 mg/mL)) pen injector is supported as medically necessary for treatment of this patients short stature. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 continuous Synvisc injections every six months for treatment of the enrollees bilateral knee arthritis. Findings:  The physician reviewer found that There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which 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. All told, the requested continuous Synvisc injections every six months are supported as medically necessary for treatment of this patients knee osteoarthritis. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Opsumit for treatment of the enrollees pulmonary arterial hypertension.  Findings:  The physician reviewer found that Current guidelines and studies have demonstrated improved health outcomes in pulmonary arterial hypertension patients who are initiated on double therapy. In addition, the U.S. Food and Drug Administration (FDA) approved a new endothelin receptor antagonist Opsumit after the SERAPHIN trial which demonstrated reduction in pulmonary arterial hypertension worsening (Pulido, et al). The majority of patients were taking a PDE inhibitor and prostanoid and remained on triple therapy throughout the study. Triple therapy has become the mainstay of therapy for pulmonary arterial hypertension patients with Class III to IV symptoms in order to address to all three pathways of disease. This patient was already treated with triple therapy and switching to a newer endothelin receptor antagonist (ERA), Opsumit from Tracleer, may benefit this patient. Thus, the requested treatment with Opsumit is supported as medically necessary for treatment of this patients 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 internal medicine with sub-specialty certifications in pulmonary disease and critical care 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.