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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgery.Findings:  Two of the three physician reviewers found that the medical records fail to demonstrate the superior effectiveness of the services at issue. The first-line treatment for intermittent claudication due to femoropopliteal occlusive disease is a supervised exercise training program along with established guideline directed medical therapy. Based upon the documentation provided, this patient underwent percutaneous revascularization without a trial of exercise training. There was no critical limb ischemia to necessitate revascularization prior to a trial of exercise. Thus, surgery was not likely to have been more efficacious than other available treatment options.  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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: A 56-year-old female enrollee has requested authorization and coverage for a power wheelchair. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees stroke.The submitted documentation does not support the medical necessity of the requested equipment. A study by Punt and colleagues reported that people with neglect tend to have more difficulty navigating obstacles when using mobility equipment than those without neglect. A new power wheelchair device was not recommended by the evaluating physical therapist for mobility post stroke as the patient can ambulate without a device. The patient has demonstrated the ability to ambulate independently and did not demonstrate the ability to safely control the power wheelchair due to left neglect and vision impairment. Therefore, the requested power wheelchair 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for catheter ablation. Findings: Two of the three physician reviewers found that this patient has frequent symptomatic right ventricular outflow tract premature ventricular beats refractory to beta-blockers, calcium channel blockers and lifestyle modification. In this circumstance, therapeutic options include additional trials of alternative antiarrhythmic medications or radiofrequency catheter ablation. Catheter ablation is a reasonable approach in this patients case and is likely to be more successful if accurate mapping can take place. Additionally, very frequent ventricular beats may lead to left ventricular dysfunction and ventricular premature beat-related cardiomyopathy. Ablation has been shown to be helpful in prevention and treatment of this process as well. Therefore, catheter ablation is likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 Lyrica 75mg capsules. Current nationally recognized evidence based medical guidelines recommend anti-epilepsy drugs (AEDs) for neuropathic pain. AEDs are recommended on a trial basis as a first-line therapy for painful polyneuropathy. Pregabalin (Lyrica) has been documented to be effective in the treatment of diabetic neuropathy and post-herpetic neuralgia. Lyrica has Food and Drug Administration (FDA) approval for diabetic neuropathy and post-herpetic neuralgia. It is considered a first-line treatment for both. Researchers concluded that clinical trial evidence supported the use of only gabapentin and pregabalin in some neuropathic pain conditions (painful diabetic neuropathy, post-herpetic neuralgia, and central neuropathic pain) and fibromyalgia. For other antiepileptic drugs there was no evidence, insufficient evidence, or evidence of a lack of effect. Under consideration is a request for Lyrica 75 mg. Current evidence based medical guidelines and peer-reviewed literature supports the use of anti-epilepsy drugs as first line treatment for neuropathic pain, including both gabapentin and Pregabalin. Therefore, a trial of Lyrica is warranted and the requested Lyrica 75 mg is medically necessary for treatment of the 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 overturnedCredentials/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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Optune Plus Transducers as well as prospective authorization and coverage for future Optune Plus Transducers treatment.Findings:  Three physician reviewers found that the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. In 2011, the U.S. Food and Drug Administration (the FDA) approved the Optune portable medical device for the treatment of recurrent glioblastoma. The Optune device generates low-intensity alternating electric fields, or tumor treatment fields (TTF). Approval was based on results of a clinical trial that randomly assigned 237 patients to either TTF therapy or chemotherapy. Similar survival was observed in the two groups, and TTF therapy was associated with lower toxicity and improved quality of life. A subsequent open-label randomized trial in patients with newly diagnosed glioblastoma showed prolonged progression-free and overall survival in the group assigned to TTF therapy when used in combination with post-radiation temozolomide. Consensus-based guidelines published by the National Comprehensive Cancer Network (NCCN) include alternating electric field therapy as a treatment option for patients as adjuvant therapy in combination with temozolomide or with recurrent glioblastoma. Therefore, the Optune Plus Transducers (CPT code E0766) provided to the patient were and are 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 and are likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with subspecialty certification in medical oncology, and they 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 gene panel testing.Findings:  Two of the three physician reviewers found that the current medical evidence supports the services at issue in this patients case. The American College of Obstetricians and Gynecologists (ACOG) recommends expanded carrier screening as an acceptable strategy for prenatal carrier screening. Screened conditions should be able to be diagnosed prenatally and have potential opportunities for antenatal intervention to improve perinatal outcomes, changes to delivery management to optimize newborn and infant outcomes, and parental education about special care needs after birth. Therefore, gene panel testing was likely to have been superior over other available methods of evaluating this patient. Final Result: The 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 1 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in clinical biochemical genetics and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 31-year-old female enrollee has requested reimbursement for inpatient hospitalization services provided on 10/16/18 for treatment of the enrollees major depressive disorder and personality disorder. Findings:  The physician reviewer found that At issue in this case is whether the inpatient psychiatric hospitalization services at issue, provided on 10/16/18, were medically necessary for treatment of the patients behavioral health condition.The American Psychiatric Association Guideline for major depressive disorder notes the determination of an appropriate setting for treatment should include consideration of the patients symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning  determination of a treatment setting should also include consideration of the patients ability to adequately care for him- or herself, to provide reliable feedback to the psychiatrist, and to cooperate with treatment of the major depressive disorder  measures such as hospitalization should be considered for patients who pose a serious threat of harm to themselves or others.Suicidal ideation is not a binary concept but a spectrum of thoughts. One is not 100 percent suicidal one day and then zero percent suicidal the next. If a patient is ill enough to be admitted for suicidal ideation, it is prudent to observe for at least one or two more days after their final documented report thereof. Given the severity of the patients illness with admission for suicidal ideation, the additional day of inpatient treatment was in accordance with generally accepted standards of medical practice, and clinically appropriate for the patient's illness, and is therefore medically necessary.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients behavioral health condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry 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: A 50-year-old female enrollee has requested authorization and coverage for the medication Xyrem for treatment of the enrollees narcolepsy.  Findings:  The physician reviewer found that At issue in this case is whether the requested medication Xyrem is medically necessary for treatment of the enrollees medical condition.Xyrem is Food and Drug Administration approved for treatment of two common symptoms of narcolepsy: excessive daytime sleepiness (EDS) and cataplexy. Alshaikh and colleagues noted that narcolepsy patients on Xyrem had significant reductions in cataplexy and daytime sleepiness. Xyrem is well tolerated in patients with narcolepsy, and most adverse events were mild to moderate in severity. Boscolo-Berto and colleagues through meta-analysis of multiple peer reviewed studies demonstrated the effectiveness of Xyrem in treating major, clinically relevant narcolepsy symptoms and sleep architecture abnormalities.The medical records indicate the patient has narcolepsy and has been treated with other treatments without sufficient response. Xyrem is a consideration given failure or incomplete response to other treatments to date.  Therefore, Xyrem is medically necessary for the 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for real time remote heart monitoring.Findings: Two of the three physician reviewers found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The use of different types of ambulatory electrocardiographic (ECG) monitoring for arrhythmias has evolved over the past 10-15 years. Guidelines from 1999-2000, the ACC/AHA guidelines for ambulatory electrocardiography, reflect that at that time, short duration monitors (24 or 48 hour) or symptom-activated external loop recorders (`event monitors`) were available. Newer systems with mobile outpatient telemetry for longer periods of time have developed more recently, and these newer systems are recommended for infrequent symptoms or when there is investigation of the cause of cryptogenic stroke and suspected atrial fibrillation. Research noted that a 2017 expert consensus statement, describe that the choice of monitor needs to be matched to the individual's symptom frequency. Use of mobile cardiac telemetry (MCT) is usually reserved for cases of infrequent symptoms or when the shorter duration monitors are negative or inconclusive. In this case, the patient was describing frequent symptoms, and there is no documentation that a shorter duration monitor had been used with results found to be negative or inconclusive. Accordingly, real time remote heart monitoring provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:All three reviewers are board certified in internal medicine, with subspecialty certification in cardiovascular disease, and are actively practicing. All three 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 inpatient treatment for radioactive iodine therapy. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees thyroid cancer.At issue in this case is whether the requested inpatient treatment for radioactive iodine therapy is medically necessary for treatment of the enrollees medical condition.The patient has metastatic thyroid cancer. She is status post thyroidectomy. She will be receiving remnant thyroid ablation with high dose (90 mci) I-131 therapy. A study note that regulatory requirements for hospitalization and other radiation protection vary among states and countries with many guidelines being more stringent than those of the Nuclear Regulatory Commission. Most states require inpatient stay if the I-131 dose exceeds 30 mci of I-131. The patient was evaluated by a nuclear medicine radiologist who has recommended that the subject be treated with I-131 therapy as an inpatient in a special room. Given the high dosage of radiation (90 mci), the inpatient level for the radioactive iodine-131 ablation for metastatic thyroid cancer is medically necessary.Final Result: The reviewer determined that the requested treatment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in 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: An enrollee has requested reimbursement for inpatient hospitalization services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees cellulitis, and flank/groin pain. At issue in this case is whether the inpatient hospitalization services provided were medically necessary for treatment of the enrollees medical condition.Inpatient hospital care is necessary when the patients signs, symptoms and general medical condition can only be managed safely in an acute inpatient setting; when the patient requires diagnostic studies in an inpatient setting; or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. He did not have a fever or elevated white blood cell count.  There was no indication in the records that he had failed treatment as an outpatient.  He was able to ambulate. His pain was reasonably controlled with oral medications, and he was hemodynamically stable. Therefore, the inpatient hospital admission was not medically necessary.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 internal 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for revision surgery to laparoscopically remove a previously implanted LINX device and to implant a new LINX device.Findings:  Three physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. The submitted medical records reflect that the patients current LINX device is functioning well and is well-seated. A post-operative EGD showed no evidence of hiatal hernia, and noted that the LINX device was in good position without erosion or migration. Furthermore, pH testing performed while the patient was off Dexilant, yielded a normal DeMeester score (9.7, normal <14.72), and only physiologic reflux without symptom correlation. Manometry has also demonstrated normal LES pressures. Despite present symptomatology, there is no medical or surgical justification to replace the patients functioning LINX device with another LINX device. Under the circumstances set forth in the submitted documentation, the patients reported distress does not appear to be acid reflux-related. A replaced LINX device would not be anticipated to correct the patients coincidental esophageal dysmotility. Accordingly, revision surgery to laparoscopically remove a previously implanted LINX device and to implant a new LINX device 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 services are not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are actively practicing and are board certified in internal medicine, with subspecialty certification in gastroenterology. 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.