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

Nature of Statutory Criteria/Case Summary: A patient with a diagnosis of alopecia universalis has requested authorization and coverage for bimatoprost. The records document that he has failed topical treatments, including Xeljanz and intralesional steroid injections. In this patient, proven treatments with intralesional steroids and Xeljanz cream for his alopecia universalis have not been substantially beneficial. However, the patient reports improvement with bimatoprost. There is evidence in limited trials demonstrating that the use of prostaglandin agents such as bimatoprost may be effective in this patient population . Studies suggest that complete regrowth may occur in up to 24% of patients. Further, the U.S. Food and Drug Administration (FDA) has approved 0.03% bimatoprost solution for the treatment of eyelash hypotrichosis. Since standard treatments have failed, it is reasonable for the patient to be treated with an FDA approved therapy for increasing eyelash length, thickness, and darkness. Therefore, the use of bimatoprost is medically necessary for 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 overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bronchoscopic thermoplasty (CPT 31660). Findings:  The physician reviewer found that Bronchoscopic thermoplasty has been approved by the U.S. Food and Drug Administration (FDA) and there are data to support its use in patients with severe persistent asthma whose symptoms persist despite maximal treatment. Further, bronchial thermoplasty has been endorsed for use in specific patients with severe persistent asthma by organizations including the American College of Chest Physicians and the American College of Allergy, Asthma and Immunology. Moreover, bronchoscopic thermoplasty has also been shown to be safe in follow-up studies. This patient presents with daily symptoms despite adequate medical therapy. She has no reported contraindication to bronchoscopic thermoplasty. Thus, the requested bronchoscopic thermoplasty (CPT 31660) is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. One reviewer found that the requested bronchoscopic thermoplasty (CPT 31660) is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Eliquis 2.5, mg two times a day for six months. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. The use of direct oral anticoagulants in patients with renal failure has not been well-studied. Some experts avoid the use of direct oral anticoagulants for patients with severe renal impairment since the efficacy remains untested. Systemic exposure increases with worsening renal function. Bleeding risk may be increased in patients with severe renal impairment. In addition, the dosage for a deep vein thrombosis is 10 mg, twice a day, for 7 days followed by 5 mg, twice a day. The dosage adjustment for significant renal impairment has not been well-established. The American Society of Hematology recommends the avoidance of direct oral anticoagulants, such as Eliquis, in patients with renal impairment. Therefore, Eliquis 2.5 mg, two times a day for six months is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in hematology 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

An enrollee has requested reimbursement and prospective authorization and coverage for 10 hours per day partial hospitalization program level of care services. The submitted documentation supports the medical necessity of the services at issue. During the disputed timeframe, the patient continued to struggle with laxative use as well as anxiety and panic. The records documented non-compliance with her meal plan. She was noted to engage in excessive exercise. The patient also engaged in self-harm behavior and expressed passive suicidal ideation on several occasions. The patient has a composite score of 20 which correlates with partial hospitalization program level of care. Therefore, 10 hours per day partial hospitalization program level of care services were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 psychiatry with sub-specialty certification in child and adolescent 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immune globulin infusion. The submitted documentation fails to demonstrate the medical necessity of the requested services. Multiple sclerosis is the most common immunologic neurological disorder of young adults. While this patient has not responded well to Copaxone, the research indicates that interferon beta-1a can be an acceptable option in the postpartum period and may be appropriate in the setting of breastfeeding. Pulse intravenous steroids have also been shown to be effective in a prophylactic and symptomatic management setting. Studies supporting intravenous immune globulin are limited at best and do not support improved outcomes when compared to other treatment options. A recent United Kingdom consensus guideline on pregnancy in multiple sclerosis states immunoglobulin should not be given to prevent post-partum relapses. Additionally, concurrent breast feeding is believed to be safe with use of interferon beta-1a and steroids. Studies and guidelines supporting intravenous immune globulin (IVIG) for the prevention of post-partum relapses are limited at best and guidelines do not endorse its use. Therefore, the requested intravenous immune globulin is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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

An enrollee has requested reimbursement for genetic testing. Although antiphospholipid syndrome has been associated with early pregnancy loss, routine testing for other thrombophilias is not recommended by the American College of Obstetricians and Gynecologists (ACOG). In addition, this patient does not have a reported personal or family history of clotting disorders to warrant testing for thrombophilias. According to the ACOG practice bulletin, no work-up generally is recommended until after the second consecutive clinical early pregnancy loss. Specifically, ACOG noted that maternal or fetal chromosomal analyses or testing for inherited thrombophilias are not recommended routinely after one early pregnancy loss. Further, from the American Society for Reproductive Medicine (ASRM), routine testing of women with recurrent pregnancy loss for inherited thrombophilias is not recommended. Accordingly, the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genetic testing was not likely to be more beneficial for evaluation of this 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral incisionless fundoplication (TIF) procedure utilizing the EsophyX device (CPT code 43210). The efficacy of transoral incisionless fundoplication (TIF) has been studied in randomized controlled trials. However, the conclusions are contradictory. The American College of Gastroenterology (ACG) guidelines for treatment of gastroesophageal reflux disease (GERD) report that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy. Researchers found that further studies are required to define optimal techniques and most appropriate patient selection criteria, and to further evaluate device and technique safety. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) do not recommend endoscopic procedures for patients with complicated GERD, which the guideline defines as dysphagia or Barretts esophagus, and report that the long-term follow-up data for TIF are limited. This patient is reported to have both dysphagia and Barretts esophagus. For these reasons, the TIF) procedure utilizing the EsophyX device (CPT code 43210) 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 TIF procedure utilizing the EsophyX device (CPT code 43210) 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 TIF procedure utilizing the EsophyX device (CPT code 43210) 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 internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The fecal laboratory testing performed in this case was recommended to evaluate the patient for various pathogens that can cause diarrhea. However, there is a lack of well-designed randomized controlled trials comparing this technology with conventional methods of testing for gastrointestinal infectious pathogens. A provider typically utilizes the clinical history obtained from the patient along with the physical examination, standard laboratory testing, radiographic data, and endoscopic evaluation to make an assessment. Currently, routine panel testing of patients who present with diarrhea is not considered the standard of care. Moreover, many of the pathogens included in the testing had a low pre-test probability of contributing to the patients presentation. For these reasons, the fecal laboratory testing services (CPT codes 82542, 82656, 82715, 82725, 83520, 83993, 84311, 87102, 87328, 87329 and 87336) were not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy has not been shown to be more safe and effective than conventional methods of testing for infectious pathogens.One reviewer found that the fecal laboratory testing services (CPT codes 82542, 82656, 82715, 82725, 83520, 83993, 84311, 87102, 87328, 87329 and 87336) were likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy has not been shown to be more safe and effective than conventional methods of testing for infectious pathogens.Final Result: Two of the three 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:  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for FoundationOne testing and associated CPT codes. Findings:  Two out of three physician reviewers found that FoundationOne is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the FoundationOne assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. One randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. For these reasons, the requested FoundationOne testing and associated CPT codes are not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. One reviewer found that the requested FoundationOne testing and associated CPT codes are likely to be more beneficial for evaluation of this 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 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 oncology with subspecialty certification in hematology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 transcatheter permanent occlusion or embolization, with flow diversion.Findings:  Three physician reviewers found that there is support for the requested services in this patients case. In the medical literature, 44 small (less than 10 mm) aneurysms of the internal carotid artery were treated with flow diversion. There was one major complication of intraprocedural rupture. The authors concluded that flow diversion is a safe treatment alternative for small internal carotid artery aneurysms. In an additional study, the safety and efficacy of flow diversion treatment for 100 consecutive patients with small (less than or equal to 7 mm) aneurysms was reported. The authors concluded that this treatment is associated with low complication rates and high aneurysm occlusion rates and is a safe and effective alternative to conventional endovascular techniques for small aneurysms. Based on the available literature, flow diversion is an effective technique for treating small aneurysms of the internal carotid artery. It may offer a decreased risk of intraoperative rupture as the aneurysm sac itself does not have to be catheterized during the procedure, particularly for small aneurysms which appear to be at increased risk of rupture during coiling compared to larger aneurysms. In this case, the patients provider is planning to treat both small aneurysms with a single flow diverting device. Deployment of a single flow diverting device is likely to be safer than catheterizing and coiling two different small aneurysms. In sum, transcatheter permanent occlusion or embolization, with flow diversion is likely to be superior over 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 neurological 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for spinal surgery. This patient experienced short-term relief from right-sided back and leg pain with prior surgery. The operative notes reported that a disc herniation was not found, nor was disc material removed, although there was evidence of local narrowing. Thus, the patient does not have recurrent herniated nucleus pulposus. Since the patient underwent a surgery, he has received eight physical therapy sessions, but there is no indication whether the patient participated in a home exercise program. There is no documentation of failure of at least 12 weeks of conservative management. In addition, the records do not report that he received epidural steroid injections or other injections. He has no documented symptoms or signs nor findings of a lumbar radiculopathy. He has no symptoms of neurogenic claudication. He has no evidence of instability. There is no documentation of nerve root compression. There is no correlation of his imaging with his clinical condition. There is no evidence of spondylolisthesis nor stenosis. For these reasons, the patient fails to fulfill the current criteria for lumbar fusion. Accordingly, the requested spine surgeryand two day stay is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.