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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica 50 mg.Lyrica is U.S. Food and Drug Administration (FDA) approved for the following indications: neuropathic pain associated with diabetic peripheral neuropathy (DPN), postherpetic neuralgia (PHN), adult patients with partial onset seizures, fibromyalgia, and neuropathic pain associated with spinal cord injury. As the FDA has not approved the use of Lyrica for lumbar radiculopathy, its use in this case would be off label. A 2019 Cochrane review of Lyrica (pregabalin) for neuropathic pain in adults concluded that studies showed limited evidence of benefit in neuropathic back pain or sciatica, neuropathic cancer pain, or polyneuropathy. The North American Spine Society clinical guidelines for managing lumbar radiculopathy found that there was not strong evidence to recommend Lyrica for lumbar radiculopathy.In this case, the patient has a 10-year history of chronic lumbar radiculopathy and she has physical exam findings that are notable for a positive straight leg test bilaterally. A new lumbar MRI has been ordered to better evaluate her back and leg complaints. The patient has tried and failed gabapentin therapy and is currently using diazepam, ibuprofen, nortriptyline, methadone, Norco, and baclofen with little benefit. Under these circumstances, where there is limited evidence to support the use of Lyrica (pregabalin) for lumbar radiculopathy, the requested Lyrica 50 mg is not medically necessary to treat 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 anesthesiology, with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for an injection of platelet-rich plasma. The enrollee was evaluated by an orthopedic surgeon for right hip pain after he sustained an injury and felt a pop in the groin. A magnetic resonance imaging scan revealed a complete avulsion of the rectus femoris. Subsequently the enrollee underwent right rectus femoris tendon repair and received a platelet rich plasma (PRP) injection as an additional procedure. Review of the record indicates insufficient evidence of all conservative care treatment options available prior to undergoing the PRP injection. There is a lack of high-quality clinical trials for PRP injections to the hip. As indications for PRP continue to expand, it will become increasingly important for future studies to state specific methodologies used in the preparation of PRP in order to recognize ideal preparation techniques and the ideal number of PRP injections for each pathology. Leukocyte-poor PRP has the advantages of a reduced inflammatory response and mainly anabolic changes compared to leukocyte-rich PRP, though further, high quality studies are necessary to determine outcome differences between these two PRP preparations. According to the literature, no definitive conclusions can be made about the effects of PRP given methodology concerns and considerable differences between studies. Further high-quality research is needed to establish the clinical benefit of PRP, which enrollees will most likely to benefit, and the optimal PRP protocol. There is a lack of high-quality clinical trials for PRP injections to the hip. Additional high-quality clinical trials with longer follow-up are critical in shaping the perspective of this treatment option.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition.Credentials/Qualifications: Three reviewers are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for genetic testing and had a skin biopsy of a right posterior thigh lesion for classification purposes. Findings:  Three physician reviewers found that the pathology report revealed an inflamed malignant melanoma, Breslows depth 0.8mm, without ulceration.  The DecisionDx- Melanoma test was ordered to help determine the enrollees risk of metastasis. The provider indicates the information this test provides can identify those with low risk disease; thus avoiding the risks associated with anesthesia and invasive testing procedures. Those identified as high-risk benefit from early sentinel lymph node biopsy and more frequent disease surveillance. The test identified the enrollees lesion as class 1, sub-class 1A. The class 1A molecular signature is associated with the lowest risk of recurrence within five years. The medical literature in support for genomic testing for melanoma is lacking for diagnostic and prognostic purposes. Recent studies are trying to gain a better understanding of the tumor microenvironment and identify a list of prognostic-immune related genes with the potential to become prognostic biomarkers. However, there has not yet been sufficient evidence to support genomic testing, such as the DecisionDx-Melanoma as the standard diagnostic and prognostic work-up for patients with cutaneous melanoma. The DecisionDx-Melanoma test is not FDA-approved. The latest clinical practice guidelines and literature only support its use for treatment consideration (i.e. immunotherapy) rather than diagnostic/prognostic testing. Genetic testing to differentiate melanoma as benign vs. malignant neoplasms, or low vs. high-risk for metastases, should not be routinely recommended outside of a clinical trial. To date, there has been no strong literature evidence to refute this recommendation. Rather, the current focus is on improving the standard of care guidelines on cancer staging, rather than genomic testing, for patient care and management. Current literature lacks clinical guidance on how to utilize genetic findings for appropriate patient care management and follow-up. To date, there is insufficient evidence to support the use of genetic testing to defer cancer staging by standard methods. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in dermatology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 56-year-old male who has a history of asthma, allergic rhinitis and hyperlipidemia. Laboratory testing revealed a vitamin D level of 30 ng/mL. Then patients vitamin D level was 31 ng/mL. There was no documented history of vitamin D deficiency or other risk factors for vitamin D deficiency. The patient has requested reimbursement for vitamin D-3 testing. The Health Plan denied the request and reported the services at issue were not medically necessary for the evaluation of this patient. At issue in this case is whether vitamin D-3 testing was medically necessary for the evaluation of the patients medical condition. The Endocrine Society Clinical Practice Guideline recommends screening for vitamin D deficiency in patients at risk for deficiency. The guidelines do not recommend screening for vitamin D deficiency in patients who are not at risk. In this case, the patient does not have a history of vitamin D deficiency, risk factors for vitamin D deficiency or symptoms suggestive of vitamin D deficiency. None of his documented medical conditions are conditions for which evaluation of vitamin D is recommended. The medical evidence does not support the services at issue in this clinical setting. Therefore, the vitamin D-3 testing was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service was 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 family 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 reimbursement for advanced lipoprotein testing. Findings:  Three physician reviewers found that the records documented that this patient had increased coronary risk. Guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, insulin, fibrinogen, and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to what is achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Therefore, advanced lipoprotein testing was not likely to have been superior over other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were not likely to have been 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for lab test related to an elevated prostate specific antigen (PSA).  His provider ordered the 4Kscore test prostate cancer risk evaluation due to a confirmed PSA greater than or equal to 3.0 ng/mL. He had no prior biopsy and no nodules.  Test results showed the enrollee was an elevated risk. The 4K score test is a lab test measuring four types of kallikreins, or enzymes, in the blood.  The test result is combined with the enrollees clinical information in an algorithm to predict the individual enrollees risk of having high grade prostate cancer, indolent prostate cancer or no prostate cancer.  This test does not obviate the need for a prostate biopsy to prove the diagnosis of prostate cancer.  Peer-reviewed studies do not support an improvement in health outcomes on the basis of this test.  It is designed to be a risk indicator for high grade prostate cancer, but has not been proven to be more beneficial than any available standard treatment.  It is not endorsed by specialty society guidelines. The guidelines indicate further risk calculators that include multiple variables (in addition to PSA) as an aid to predicting the risk of prostate cancer have not been proven to increase the benefit to harm ratio, and their value in predicting cancer on biopsy is not necessarily generalizable to a population that differs from that in which the tool was developed. Some literature indicates this testing may be appropriate in specific circumstances, but there is no documentation to substantiate this enrollee is an appropriate candidate. There is insufficient evidence in the record of a repeat prostate biopsy following a prior negative biopsy result. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in urology 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: The patient is a transgender female who was diagnosed with gender dysphoria. The patient reported that she was interested in voice training. Per the submitted documentation, the patient began hormone therapy, but her gender dysphoria persisted due to the low pitch of her voice, which manifests as anxiety, depression, and agoraphobia. The patient requested authorization and coverage for vocal therapy consisting of (office/outpatient visit new), (laryngoscopy telescopic), (speech/hearing therapy), (laryngeal function studies), and/or (behavioral quality analysis voice). The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether vocal therapy consisting of (office/outpatient visit new), (laryngoscopy telescopic), (speech/hearing therapy), (laryngeal function studies), and/or (behavioral quality analysis voice) is medically necessary for the treatment of the patients medical condition. Voice and communication therapy is a treatment option for transsexual, transgender, and gender nonconforming patients in order to maximize their overall health, psychological well-being, and self-fulfillment In this case, the patient endorsed persistent gender dysphoria due to the low pitch of her voice, which manifests as anxiety, depression, and agoraphobia. The medical evidence supports the requested services in this clinical setting. Therefore, vocal therapy consisting of (office/outpatient visit new), (laryngoscopy telescopic), (speech/hearing therapy), (laryngeal function studies), and/or (behavioral quality analysis voice) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: An enrollee has requested authorization and coverage for proton beam radiation therapy. The patient has undergone previous radiation. Compared to standard treatment with photons, proton beam radiation therapy would be able to deliver a lower integral dose to the patients surrounding tissues. This could potentially lead to decreased toxicities of the surrounding tissue compared to standard treatment. In cases of re-irradiation, proton beam radiation therapy has been shown to decrease toxicities. Therefore, proton beam radiation therapy 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 radiation oncology 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 advanced lipoprotein testing.Findings:  Three physician reviewers found that this patient has several risk factors for cardiovascular disease. Per the American College of Cardiology/American Heart Association (ACC/AHA) guidelines, statin therapy is indicated in this clinical setting. Per the records, this patient was already on low dose statin therapy. Based on current ACC/AHA guidelines, aggressive lifestyle modification and medium to high dose statin therapy were indicated to achieve a low-density lipoprotein (LDL) level of 70 or lower. Additional risk stratification with advanced lipid profile testing, such as apolipoprotein B, may be appropriate when there is a question about the need for aggressive pharmacologic lipid lowering therapy. In this case, the patient already had a guideline-directed indication for therapy based on her risk factors and standard lipid testing. Therefore, advanced lipoprotein testing was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to have been 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for RT300 functional electrical stimulation (FES) cycle therapy system. Findings:  Two of the three physician reviewers found that there is a lack of support for the requested device in this clinical setting. Ralston and colleagues noted that there were no clear effects of functional electrical stimulation (FES) cycling on urine output, swelling and spasticity even though all point estimates of treatment effects favored FES cycling and participants perceived therapeutic effects. This patient presents with tetraplegia and associated neurological deficits in the bilateral upper and lower extremities below the C5 level. At this time, there is a lack of definitive clinical research demonstrating the benefit of FES units as an adjunct treatment for spinal cord injury. Therefore, the requested RT300 FES cycle therapy system is not likely to be more effective than other treatment options.Final Result: The reviewers determined that the requested device is 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 physical medicine and rehabilitation 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 was diagnosed with alcohol use disorder, alcohol withdrawal syndrome, and transaminitis. Patient was discharged from a chemical dependency detoxification unit and admitted for residential treatment. The patient had requested reimbursement for residential treatment center (RTC). The Health Plan denied the request and reported the services were not medically necessary for the treatment of this patient. At issue in this case is whether RTC services were medically necessary for treatment of the patients medical condition. The patient was admitted to a RTC with a history of alcohol use with associated mood symptoms due to substance use. He denied a history of suicidal ideation or suicide attempts and denied inpatient psychiatric treatment. The patient did not exhibit acute withdrawal symptoms during RTC treatment. The patient did not report any significant medical issues. The patient did not have a plan or intent of self-harm and did not engage in any self-harm behaviors during treatment. No aberrant behavior was noted during his RTC admission. Medical literature shows, continued stay and discharge of patients with addiction and co-occurring conditions. For acute intoxication and/or withdrawal potential, the patients score is 0. For biomedical condition and complications, the patients score is 0. According to the ASAM criteria, all six dimensions must be met for placement in the RTC level of care. The patients presentation did not meet the required six out of six dimension criteria. The medical evidence does not support the services at issue in this clinical setting. Therefore, RTC services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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 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.