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 and prospective authorization and coverage for laser treatment (CPT 17108).Findings:  Three physician reviewers found that rosacea is a common chronic disorder characterized by periods of exacerbation, remission and possible progression. The nonpharmacologic approach to therapy includes adequate skin care, trigger avoidance and photoprotection. In addition, there are several topical, herbal, systemic and light-based therapies available. U.S. Food and Drug Administration (FDA) approved treatments include topical metronidazole and azelaic acid. Combinations of azelaic acid or topical metronidazole with anti-inflammatory doxycycline appears to have a synergistic effect. The standard approach for the treatment of patients with rosacea is to combine the systemic anti-inflammatory effect of tetracycline antibiotics with topical anti-inflammatory and bactericidal treatments. In this case, the records do not document that this patient has failed standard treatments. Laser treatment is not supported in this setting. Therefore, laser treatment (CPT 17108) was not and is not likely to have been of greater benefit than other treatment options. 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: Physician reviewers 1, 2 and 3 are board certified in dermatology 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 5000 units of rimabotulinumtoxinB every three months by injection. There is a lack of peer-reviewed publications regarding the use of rimabotulinumtoxinB for treatment of dysphagia associated with ALS. There is data supporting the effectiveness of botulinum toxin type A as effective for dysphagia related to ALS. The records do not indicate a rationale for using type b toxin or indicate a contraindication to type A toxin. Moreover, the literature does not support the requested regimen of 5000 units of rimabotulinumtoxinB in lieu of the 2500 units approved by the Health Plan. All told, the requested 5000 units of rimabotulinumtoxinB every three months by injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested 5000 units of rimabotulinumtoxinB every three months by injection 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 5000 units of rimabotulinumtoxinB every three months by injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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 shock wave therapy. The Health Plan has denied this request as investigational for the treatment of the enrollees right lateral epicondylitis. Nationally recognized evidence based medical guidelines do not recommend shock wave therapy to treat elbow conditions including lateral epicondylitis. Moreover, clinical trials have yielded conflicting results. There was mixed evidence for lack of benefit of shock wave therapy for lateral epicondylitis. A study concluded that there are multiple randomized controlled trials for non-surgical management of lateral epicondylitis, but the existing literature does not provide conclusive evidence that there is one preferred method of non-surgical treatment for this condition. It was noted that shock wave therapy did not appear to provide definitive benefit regarding pain relief. This patient presents with right lateral epicondylitis. He has reportedly failed to improve with activity modification, massage, physical therapy, corticosteroid injections and medications. However, the evidence based medical guidelines and peer-reviewed medical literature do not support shock wave therapy in this patients medical condition based on inconclusive evidence. Thus, the requested shock wave therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested shock wave therapy is 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 requested services 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Supartz injections for the right knee. Findings:  Two of the three physician reviewers found that the peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and has been showed to be more effective than corticosteroid injections. In this case, the patient presents with recurrent right knee pain, swelling, and giving way. Clinical examination findings were consistent with radiographic evidence of moderate osteoarthritis. He has failed to respond adequately to other conservative treatment, including nonsteroidal anti-inflammatory drugs, opioid medication, and corticosteroid injection. Prior hyaluronan acid injections have provided excellent pain relief for at least six months. Therefore, the requested Supartz injections for the right knee are likely to be superior over other available 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 orthopedic surgery 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 sensory integration occupational therapy. Sensory integration occupational therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Various forms of sensory stimulation are often combined with purposeful muscle activities, with the goal of improving how the brain process and organizes sensory information. Sensory integration therapy has been a popular treatment for children with neurodevelopmental disorders such as autism and developmental delay but there is significant controversy regarding its effectiveness. In the medical literature, researchers noted that sensory integration therapy remains a controversial treatment method supported by limited scientific data. At present, there is insufficient evidence in the medical literature to support the use of sensory integration occupational therapy in this clincial setting. Thus, the requested sensory integration occupational therapy is not likely to be more beneficial for treatment of the patients medical condition than any standard available therapy.One reviewer found that the requested sensory integration occupational therapy is likely to be more beneficial for treatment of the patients medical condition than any standard available therapy.Final Result: Two of the three reviewers determined that the requested services 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:  One reviewer is board certified in pediatrics, neurodevelopmental behavioral pediatrics, and genetics and is actively practicing. One Reviewer is board certified in pediatrics and neurology with special qualification in child neurology and is actively practicing.  One Reviewer is board certified in pediatrics with expertise in developmental and behavioral pediatrics and is 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Helicobacter pylori (H. pylori) antibody blood testing. In the current peer-reviewed medical literature, researchers noted that H. pylori infection can be clinically challenging, given the numerous diagnostic and therapeutic options available. Researchers reported that a urea breath test or the stool antigen test can be used for non-invasive screening for H. pylori in younger patients presenting with dyspepsia without alarm symptoms without the need for endoscopic prelude to therapy or retreatment. Further, researchers discussed that serologic testing is not recommended as the standard of care. Since the antibodies to H. pylori can remain elevated for a long time after treatment, evaluation with serologic testing has a greater potential for false-positive results. All told, the H. pylori antibody blood testing was not likely to have been more beneficial for evaluation of this patients symptoms than standard testing with stool antigen or urea breath assays. One reviewer found that the H. pylori antibody blood testing was likely to have been more beneficial for evaluation of this patients symptoms than standard testing with stool antigen or urea breath assays.Final Result: Two of the three reviewers determined that the service 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostatic urethral lift, UroLift procedure.  Findings:  The physician reviewer found that Recent clinical trials have shown that the UroLift procedure is safe and effective in relieving lower urinary tract symptoms due to benign prostatic hyperplasia without significantly compromising sexual function. Compared with transurethral resection of the prostate, the UroLift procedure is a minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time. A recent prospective, randomized, multinational study by Sonksen and colleagues compared the outcome of prostatic urethral lift to transurethral resection of the prostate. The authors concluded that patients who underwent prostatic urethral lift responded significantly better than those who underwent transurethral resection of the prostate. Thus, prostatic urethral lift, UroLift procedure is likely to be more effective than other treatment options. Final Result: Two of three 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the medication Omnitrope Pen 10. The submitted documentation does not support that the requested medication is medically necessary. In 2016, a published guidelines and recommendations for growth hormone (GH) use. These guidelines indicate that the decision to treat patients with idiopathic short stature (ISS) should be made on case-by-case basis. The guidelines also suggested that a follow-up assessment of benefit in Height SDS and psychosocial impact should be performed 12 months after GH initiation and dose optimization. In this case, the patient has been on growth hormone off and on due to a history of poor compliance. The patient has not started puberty yet, and he continues to maintain a delay in bone age versus chronological age. His last height prediction is more than the mid-parental height. The patient has been prescribed growth hormone therapy for 5 years, but he has shown a poor response to GH therapy, which could be due to poor compliance or partial resistance to growth hormone action. He has poor growth velocity despite the fact that he has been on growth hormone therapy, hence he did not experience any significant benefit from GH treatment. At the current stage, the patients predicted adult height is better than the mid-parental height, and growth hormone therapy has not benefited him in the past 5 years. Under these circumstances, the medical records do not support that there is benefit in treating this patient further with growth hormone therapy. Accordingly, Omnitrope Pen 10 is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics, with subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for single photon emission computed tomography (SPECT) brain scan (procedure code 78607).Findings:  Three physician reviewers found that the patient was evaluated for mood changes and irritability, for which SPECT study was performed. While SPECT scanning has shown promise in the evaluation of several neurological conditions, routine use of SPECT scans for diagnosis and treatment is yet to be established in this clinical setting. There is a lack of support for SPECT scans for neuropsychiatric disorders without evidence of cerebrovascular disease. In sum, SPECT brain scan (procedure code 78607) was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX colon cancer assay.Findings:  Three physician reviewers found that adjuvant chemotherapy is of benefit to patients with stage III (node-positive) colon cancer. It is much more controversial as to the usefulness of adjuvant chemotherapy in stage II colon cancer, as in this patients case. Most providers make this decision based on specific pathologic and clinical features. Among the main features that predict for a higher risk of recurrence are poorly differentiated cancer, lymphovascular invasion, presentation with obstruction or perforation, or a T4 tumor. None of these features are applicable in this patients case. Oncotype DX colon cancer assay is a 12-gene panel that can predict for recurrence in stage II and to some degree in stage III patients. However, in this patients case, it is not clear whether the assay could be used to administer adjuvant chemotherapy, or that the data from the assay is superior to the criteria noted above. There is a lack of support for the use of Oncotype DX colon cancer assay to make decisions about adjuvant chemotherapy in patients with stage II colon cancer, especially for patients with good clinical features. In sum, Oncotype DX colon cancer assay was not likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anterior segment optical coherence tomography (OCT) services. The standard therapy for this patient with glaucoma suspicion is comprehensive ophthalmologic examination with the addition of gonioscopy to evaluate the anterior chamber angle. Anterior chamber OCT has been reviewed and assessed for its usefulness by the American Academy of Ophthalmology (AAO). Although the AAO did not take a final position on the usefulness of this imaging, the Technology Assessment committee concluded that there have been no appropriately powered longitudinal clinical studies demonstrating that imaging can be used to predict the future development of primary angle closure (PAC). Overall, reviews of the current literature suggest that further studies are needed to clarify whether the anterior segment OCT findings are useful for glaucoma management. Thus, the anterior segment OCT services were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the anterior segment OCT services were 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 anterior segment OCT services were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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 radiofrequency ablation services. Based on the patients physical presentation and history, the requested radiofrequency ablation is not likely to provide this patient with an improved health outcome when compared with standard therapies. In the medical literature, radiofrequency ablation may provide long-term results in well selected patients. However, the current studies have included fibroids measuring 6-7 cm in maximum size. Given the lack of long-term data of the radiofrequency ablation, uterine artery embolization or hysterectomy would likely be more effective treatment options for this patient than radiofrequency ablation. Thus, the requested radiofrequency ablation services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested radiofrequency ablation services are 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 radiofrequency ablation services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 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.