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 RT300 Functional Electrical Stimulation (FES) Therapy System (HCPCS code E1399). The RT300 FES Therapy System provides passive exercise in individuals with neurological weakness by using topical electrical stimulation leads to activate paralyzed limb muscles to drive a stationary cycle. The data from the medical literature, however, has not demonstrated that use of this device improves function or health outcomes in a clinically significant manner for persons with spinal cord pathology. According to Hofer and Schwab, FES does not promote neurological recovery beyond natural recovery and does not improve cardiovascular health, pulmonary health or other health parameters in a clinically significant manner. FES may help to improve or maintain muscle mass in weakened or totally paralyzed limbs, but this provides no significant health or functional benefit in this clinical setting because the muscle tissue that is gained or spared does not provide any clinical or functional benefit. Moreover, Tweedy and colleagues state that health and well-being in this patient population should be promoted with active exercise using volitionally intact muscles and general encouragement of active participation in educational, social, recreational, avocational activities, and vocational activities. In this case, the addition of FES cycle ergometry is not expected to marginally improve health or functional outcomes. Thus, the requested RT300 Functional Electrical Stimulation (FES) Therapy System (HCPCS code E1399) is not medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for radiofrequency ablation of a thyroid nodule. This patient presents with a thyroid nodule that has demonstrated benign pathology on two fine needle aspirations. Thyroid nodules are a frequent finding on physical examination and on unrelated radiographic studies. Although most thyroid nodules are benign, current data suggests that approximately 10-15% of thyroid nodules are malignant (Pemayun, et al.). Benign thyroid nodules have the potential for malignant transformation and may cause compressive symptoms such as dyspnea and hoarseness. In this clinical setting, these nodules may require treatment (Chen, et al.). Thermal ablation using radiofrequency is a minimally invasive modality employed as an alternative to surgery in patients with benign thyroid nodules and recurrent thyroid cancers (Kim, et al.). Radiofrequency ablation may reduce the size of thyroid nodules and can lead to improvement in pressure symptoms and overall patient satisfaction (Guang, et al.). For these reasons, the requested radiofrequency ablation of a thyroid nodule is medically necessary for 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 internal medicine with subspecialty certification in diabetes, endocrinology, 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for left ear cochlear implant placed post labyrinthectomy and associated two-day inpatient hospital stay. The records provided for review document that this patient has a history of Menieres disease with unilateral hearing loss. The patient underwent simultaneous labyrinthectomy and cochlear implantation. Prior treatment has included a hearing aid. Labyrinthectomy with simultaneous cochlear implantation has been performed successfully for well selected patients with Menieres disease and associated hearing loss (Villavisanis, et al.). Perkins and colleagues noted that patients with unilateral Menieres disease who underwent simultaneous labyrinthectomy and cochlear implantation experienced improvements in sound localization, speech understanding, tinnitus severity, and quality of life with device use. Given this support, the left ear cochlear implant placed post labyrinthectomy and associated two-day inpatient hospital stay were medically necessary for this patient.  Final Result: The reviewer determined that the services at issue were 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 otolaryngology 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: The patient has requested authorization and coverage for Opdivo (nivolumab). The U.S. Food and Drug Administration (FDA) approves the use of Opdivo (generic name nivolumab), as a single agent or in combination with ipilimumab, for the treatment of microsatellite instability-high or mismatch repair deficient metastatic colorectal cancer that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan. The combination of regorafenib and nivolumab is not supported by the FDA or under the National Comprehensive Cancer Network (NCCN) guidelines for the treatment of rectal cancer. In this case, the patient has stage IV colon cancer. Given that current medical literature does not support the use of nivolumab in combination with regorafenib, the requested medication is not medically necessary. Therefore, Opdivo (nivolumab) is not medically necessary for the treatment of this patient.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 internal medicine with sub-specialty certifications in medical oncology and 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Invitae Nephrolithiasis Panel genetic testing. The records provided for review document that this patient has been diagnosed with familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC). Affected patients usually present in childhood or adolescence with symptomatic hypocalcemia. Mutations in the claudin-16 gene are the major known cause of FHHNC, which was established in this patient. Given this support for the patients diagnosis, the requested genetic testing comprised of a nephrolithiasis panel is not indicated to direct in treatment planning. Therefore, the requested Invitae Nephrolithiasis Panel genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Invitae Nephrolithiasis Panel genetic testing is 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 requested services are not likely to be more beneficial for treatmevalent of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in nephrology and is actively practicing. Physician reviewer 2 is board certified in urology with subspecialty certification in pediatric urology and is actively practicing. Physician reviewer 3 is board certified in urology 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: An enrollee has requested authorization and coverage for Synvisc-One (hyaluronan) injection in both knees.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has received excellent benefit from viscosupplementation with Synvisc-One in the past. Furthermore, the options are limited. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties. Therefore, the requested Synvisc-One (hyaluronan) injection in both knees is medically necessary for the treatment of the patients medical condition.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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for RT300 functional electrical stimulation (FES) therapy system. Review of this patients records reports spasticity due to his spinal cord injury (SCI) and upper motor neuron injury. Recently published systematic reviews on the effects of FES in chronic SCI patients have demonstrated the beneficial effects of FES use on spasticity in the lower extremities and avoiding long-term complications of a severe SCI. Specifically, FES cycling has been shown to have positive effects on muscle size, strength, and function, as well as skin thickness, and cardiovascular and bone health. Sadowsky and colleagues evaluated a retrospective cohort of patients with chronic SCI and compared those performing long-term FES cycling to those involved in a standard protocol of range-of-motion and stretching exercises. The authors concluded that in the patients undergoing treatment with FES, muscle mass and strength were improved as well as quality of life and daily function measures. Overall, the current peer-reviewed medical literature supports RT300 FES use in this patient who is in the chronic phase after a complete SCI to improve overall health and potentially limit complications of the disability. For these reasons, the requested RT300 FES therapy system is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that the records show that the patient has tried and failed three psychotropic medications in the same class. The records do not document that the patient has tried serotonin-norepinephrine reuptake inhibitors (SNRIs), antipsychotics, mood stabilizers, or dopamine reuptake inhibitor agents. While TMS may be recognized for the treatment of depression in patients who have not benefited from treatment with antidepressant medications, given that this patient has only tried three psychotropic medications in the same class, the requested service is not medically indicated. In this patients case, TMS is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, TMS 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 psychiatry with sub-specialty certification in geriatric 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 Psychological Testing. Findings:  The physician reviewer found that sychological testing is to be used in conjunction with other sources of clinical information to create a diagnostic formulation and treatment recommendations. These multiple sources of clinical information include clinical interview, interviews with collateral sources, self-report objective measures, observation of the patient, and review of past records. The appropriate use of psychological and neuropsychological testing is to assist in narrowing the differential diagnosis when there is a lack of diagnostic clarity or a lack of progression in a patients treatment plan due to possible functional and cognitive limitations, which are not able to be elucidated in the course of clinical interview and treatment.In this case, while the patient has requested psychological testing for the purpose of diagnosing or treating a condition and its symptoms, the present request is for psychological testing in the absence of other sources of clinical information. APA Guidelines establish that psychological testing is to be used in conjunction with other sources of clinical information to create a diagnostic formulation and treatment recommendations. These other sources of clinical information include clinical interviews, interviews with collateral sources, self-report objective measures, observation of the patient, and review of past records. The submitted documentation, however, indicates that the patient has not previously participated in therapy and that her care to date has been limited to a single intake interview with a psychologist. There has therefore been no documented, full clinical evaluation performed to date that is based on clinical interviews, interviews with collateral sources, self-report objective measures, observation of the patient, or review of past records. There is also no diagnostic lack of clarity that is informed by any such clinical information. Psychological testing under these circumstances is not in accordance with the generally accepted standards of mental health care. Accordingly, the requested Psychological Testing is not medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the requested services are not medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gamunex-C intravenous immunoglobulin (IVIG). Standard treatment of small fiber neuropathy is dependent on the underlying etiology (Hovaguimian and Gibbons). Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions (Liu, et al.). IVIG is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. In a retrospective study by Liu and colleagues, 55 patients with objectively confirmed small fiber polyneuropathy attributed to autoimmunity received IVIG for more than three months. The authors concluded that their results provide Class IV evidence demonstrating that IVIG is safe and effective for rigorously selected small fiber polyneuropathy patients with apparent autoimmune causality. In this case, the patient has small fiber neuropathy with a positive trisulfated heparin disaccharide (TS-HDS) antibody titer. Based on the current peer-reviewed medical literature, patients with autoimmune small fiber neuropathy may clinically improve with IVIG (Levine). Given this support, the requested Gamunex-C IVIG is medically necessary for treatment of this 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: Medical Necessity
Decision: Upheld Decision of Health Plan

ature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral medial branch block injections. Findings:  The physician reviewer found that herapeutic facet injections have not been shown to provide long-term utility. Kwak and colleagues found that intraarticular lumbar facet joint corticosteroid injections were effective, regardless of facet joint osteoarthritis severity. However, the long-term effects of intraarticular lumbar facet joint corticosteroid injections were not evaluated. Thus, further studies are required to overcome these limitations and support the results of the present study. This patient is being treated for low back and neck pain with radiation to the bilateral shoulders and upper extremities, bilateral hips, and bilateral lower extremities. Physical examination revealed that Gaenslens and Faber tests were positive bilaterally. The patients strength was 4/5 in the lower extremity flexors and 3/5 in the lower extremity extensors. The provider also noted decreased tone in the bilateral lower extremities. The provider reported that the patient has undergone previous lumbar medial branch blocks followed by lumbar radiofrequency ablation. However, detailed documentation is not evident regarding any significant, sustained functional improvement, or decrease in pain levels following these procedures to support an indication for additional medial branch blocks. Furthermore, there is plausible evidence of radiculopathy. All told, the requested bilateral medial branch block injections at L2, L3, L4 and L5 levels are 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 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.