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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for percutaneous tibial nerve stimulation (CPT code 64566) and prospective authorization and coverage for percutaneous tibial nerve stimulation (CPT code 64566) for seven weeks in order to complete the initial 12-week treatment plan and then every three to four weeks for maintenance.Findings:  Two of the three physician reviewers found that the current medical evidence has not established the superior efficacy of the services at issue in this setting. There is a lack of reliable data regarding maintenance percutaneous tibial nerve stimulation. Percutaneous tibial nerve stimulation is considered a third-line therapy in this clinical setting, and this modality has not been demonstrated to be more effective than anticholinergic or antimuscarinic therapy. There are alternatives which are safe for this patient. Therefore, percutaneous tibial nerve stimulation (CPT code 64566) was not likely to have been of greater benefit than other treatment options. Additionally, the superior effectiveness of future percutaneous tibial nerve stimulation (CPT code 64566) for seven weeks in order to complete the initial 12-week treatment plan and then every three to four weeks for maintenance has not been demonstrated. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gallbladder surgery with gallstone removal. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees gallstones.At issue in this case is whether the requested gallbladder surgery with gallstone removal is medically necessary for treatment of the patients medical condition.Per a study, gallstones grow inside the gallbladder or biliary tract. These stones can be asymptomatic or symptomatic; only gallstones with symptoms or complications are defined as gallstone disease. Diagnosis is mainly based on clinical symptoms, abdominal ultrasonography and liver biochemistry tests. Symptoms often precede the onset of the three common and potentially life-threatening complications of gallstones (acute cholecystitis, acute cholangitis and biliary pancreatitis). Researchers indicate that gallstones are common in certain areas, affecting an estimated one in seven adults. Fortunately, they are asymptomatic in up to 80 percent of cases, and current guidelines do not recommend cholecystectomy unless they cause symptoms. The patient has had chronic right upper quadrant and abdominal pain for over one year. The patient has had other symptoms occasionally including nausea, vomiting and diarrhea. Work up has generally otherwise been negative, with positive findings of cholelithiasis, polyp and sludge on gallbladder ultrasound with transient elevation of liver function tests previously. Gastric emptying study is normal. Magnetic resonance imaging shows cholelithiasis without other masses or causes of abdominal pain. The patient likely has chronic cholecystitis and there is no other finding in the area to support other etiology of pain. Gallbladder surgery with gallstone removal is indicated for symptomatic cholelithiasis and right upper quadrant pain without any other clear etiology after thorough work up. Therefore, the gallbladder surgery with removal of gallstones is medically necessary. Final Result: The reviewer determined that the requested procedure 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 general surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computer assisted musculoskeletal surgical navigation system procedure.Findings:  Two of the three physician reviewers found that this patient presented with a history of left medial knee pain and dysfunction. X-rays of the left knee demonstrated medial joint space narrowing. There was imaging evidence of a new tear of the posterior root attachment of the medial meniscus with 3 mm extrusion of the body, and progression to grade 4 chondral loss in the weight bearing medial compartment with subchondral edema. She underwent left knee medial unicompartmental knee replacement with computer assisted navigation. Computer-assisted surgery for the partial knee arthroplasty is not supported by evidence-based medical guidelines or peer-reviewed literature. There is a lack of large volume, high-quality clinical trials that confirm the clinical benefits of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. In sum, computer assisted musculoskeletal surgical navigation system procedure was not likely to have been more effective than other treatment options. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in 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 reimbursement for the Cartiva implant (synthetic cartilage implant). Based on current medical literature, the Cartiva implant was not likely to provide this patient with a superior health outcome when compared to standard treatment modalities. Standard implants and joint fusion has been shown to provide positive health outcomes in this clinical setting. By comparison, the Cartiva implant has not been demonstrated in randomized controlled clinical trials to be safe and effective at long-term follow-up. All told, the Cartiva implant (synthetic cartilage implant) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the Cartiva implant (synthetic cartilage implant) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in podiatry and is actively practicing. One Reviewer is board certified in podiatry and is actively practicing.  One Reviewer is board certified in podiatry 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 the upper endoscopy with radiofrequency ablation (RFA) services. Currently accepted practice guidelines from gastroenterology societies support the use of RFA in Barretts esophagus when high-grade dysplasia is present, and in some cases in which low-grade dysplasia is present. However, there are no recommendations supported by high-quality evidence to perform ablation in patients with indefinite dysplasia or non-dysplastic Barretts esophagus. Specifically, the most recent American Society for Gastrointestinal Endoscopy guideline does not recommend RFA of non-dysplastic Barretts esophagus unless a special circumstance such as family history of cancer is present. Further, the American College of Gastroenterology recommendations do not recommend RFA of Barretts esophagus without definite dysplasia. As there is no documented evidence of dysplasia of Barretts esophagus in this case, the upper endoscopy with RFA services were not likely to be more beneficial for treatment of the patients Barretts esophagus than any available standard therapy.Findings:  Three physician reviewers found the upper endoscopy with RFA services were not likely to be more beneficial for treatment of the patients Barretts esophagus than any available standard therapy.Final Result: The reviewers determined that the upper endoscopy with RFA services were not likely to be more beneficial for treatment of the patients Barretts esophagus 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 15 hours of direct applied behavior analysis weekly. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees autism. The patient has been receiving applied behavior analysis (ABA) services from the provider and has made gains in many service areas. There was reports of challenging behaviors including aggression and lack of safety awareness. There were difficulties with communication. Current goals included safety, communication, tacting, and executive functioning skills. The medical records indicated slow progress with the current care plan; however, that may have been due to increasingly complex goals. A study found identifies applied behavior analysis (ABA) as the most effective form of treatment for children on the autism spectrum. Study results indicated that dose of treatment was positively associated with the number of mastered objectives, indicating that treatment that is more intensive leads to quicker and greater acquisition of skills. Thus, limiting access to treatment hours would have a negative impact, with fewer goals being mastered and duration of treatment lasting longer. The BACB guidelines specifies that supervision should occur for 20% of direct service time, or a minimum of 2 hours per week. As the provider is requesting 15 hours of direct treatment, the corresponding amount of supervision would be 3 hours per week.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 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: A female enrollee has requested authorization and coverage for endoluminal ablation of varicose veins. Findings: The physician reviewer found that in this case, there is no evidence of significant venous reflux in the GSV distribution. While there is some evidence of some reflux, a recent ultrasound did not demonstrate blood flow greater than the required threshold at the saphenofemoral junction. Therefore, the requested endoluminal ablation of varicose veins is not medically necessary. 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 general surgery and vascular 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: A female enrollee has requested authorization and coverage for Mavyret for eight weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. Moreover, the guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret for eight weeks, is supported as medically necessary for the treatment of this patients hepatitis C infection.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 internal medicine with sub-specialty certification in gastroenterology 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee has requested authorization and coverage for Euflexxa injections. As evidenced by the history of significant benefit from these injections in a large number of patients; the current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Given this patients clinical presentation and prior treatment with NSAIDs and corticosteroid injections, viscosupplementation for longer term pain relief is medically necessary. Therefore, Euflexxa injections of the right knee are medically necessary.Final Result: The reviewer determined that the requested treatment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees squamous cell carcinoma of the tonsil. At issue in this case is whether the requested proton beam radiation therapy is medically necessary for treatment of the enrollees medical condition.Current clinical data does not suggest that treatment with proton beam radiation offers a clinical benefit; when compared to conventional radiation therapy techniques for tumors of the head and neck area. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT). A recent comparative analysis of proton therapy compared to photon therapy found no significant difference in symptom burden in the acute and chronic phases; for head and neck cancer. Also, the American Society of Radiation Oncology (ASTRO) emerging technology committee report on proton therapy specifically states that there is insufficient data to recommend proton beam therapy; for routine head and neck radiation therapy outside of clinical trials. Consensus group guidelines do not support the use of proton therapy in this setting (National Comprehensive Cancer Network). Also, there is no level I evidence to support the use of proton therapy for the treatment of head and neck cancer. Therefore, proton beam radiation therapy is not medically necessary in this case.Final Result: The reviewer determined that the requested treatment 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) infusions.Findings:  Two of the three physician reviewers found that PANDAS is a term used for children that have abrupt onset of tics and/or obsessive-compulsive disorder symptoms following group A beta hemolytic streptococcal infection. There has been debate over optimal and appropriate treatment for children that carry this diagnosis. Many children respond to bacterial eradication. Some children remain symptomatic despite multiple courses of antibiotics and symptomatic treatments for the behavioral concerns. For this latter group of patients, the use of IVIG has become standard of care to address more complex diagnoses, such as immunoglobulin G (IgG) deficiency and autoimmune encephalitis. The current standard of care involves use of immunomodulatory agents for more complex and/or refractory cases. This patient represents such a case, with persistent symptoms despite multiple courses of antibiotics, as well as other therapies, such as selective serotonin reuptake inhibitors (SSRI) therapy. The use of IVIG is standard of care in this setting. Therefore, IVIG infusions are likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in pediatrics with sub-specialty certification in pediatric critical care medicine and are actively practicing. Physician reviewer 3 is board certified in pediatrics 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement, authorization, and coverage for intensive outpatient program services. The Health Plan has denied this request indicating that the services at issues were not and are not medically necessary for treatment of the enrollees behavioral health condition. At issue in this case is whether the intensive outpatient program (IOP) services were and are medically necessary for treatment of the patients behavioral health condition. The patient began the intensive outpatient program services. The progress notes do not reflect severe regular emotional outbursts or other issues that would warrant intensive treatment. The progress notes indicate the patient is mostly cooperative in treatment but is often sarcastic, and is not very invested in treatment. The treatment goals are largely related to chronic issues of disrespect.The patient is not aggressive with anyone in the program and does not exhibit emotional or physical outbursts during the IOP sessions. Her mood is relatively stable throughout her sessions. The major issues are her relationship with her parents and disrespect towards them. She has not expressed any suicidal or homicidal ideation or psychosis. She was noted to be free from suffering behaviors for over six months. The records do not indicate that she has used any substances during the dates at issue. Therefore, the intensive outpatient program services were not and are not medically necessary.Final Result: The reviewer determined that the requested services were not and 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 psychiatry with subspecialty 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.