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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pulsed radiofrequency of the right knee. As discussed in the peer-reviewed medical literature, pulsed radiofrequency is not supported as a safe and effective treatment for knee pain. A study found a small-randomized trial that concluded; further clinical trials need to be undertaken, with a larger sample size, in order to demonstrate the efficacy of this technique. Researchers noted that adverse vascular events have been reported and the long-term efficacy and adverse events are still largely unknown. All told, the requested pulsed radiofrequency of the right knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: One reviewer found that the requested pulsed radiofrequency of the right knee is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Two of the three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: One reviewer is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. One Reviewer is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. One Reviewer is board certified in anesthesiology with subspecialty certification in pain 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX Prostate Assay. Findings:  Three physician reviewers found that there are three basic approaches to the treatment of localized prostate cancer. These approaches are surgical prostatectomy, radiation, or active surveillance. The latter approach involves careful follow-up, but no specific treatment for the cancer. Treatment recommendations are based on risk stratification, which is a method incorporating clinical and pathologic findings. A further refinement of prognostication is the use of gene panels, such as Oncotype DX Prostate Assay. This is a 17-gene panel that is increasingly used to guide initial treatment for localized prostate cancer. There is sufficient support for the services at issue in this clinical setting. Therefore, Oncotype DX Prostate Assay was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation 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 internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital stimulator implantation of electrodes. The criteria for diagnosis of occipital neuralgia require severe paroxysmal, lancinating pain in the distribution of the occipital nerves, a positive Tinels sign, and dysesthesia with palpation. This patient does not meet the criteria since her pain is chronic, occasionally shooting to the eye, and there is no documentation of a positive Tinels sign or dysesthesia with palpation. Overall, the records do not support a diagnosis of occipital neuralgia. Moreover, surgical occipital nerve stimulation is not consistent with the current standard of care. Given these findings, the requested occipital stimulator implantation of electrodes is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: One reviewer found that the requested occipital stimulator implantation of electrodes is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Two of the three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: One reviewer is board certified in neurosurgery and is actively practicing. One Reviewer is board certified in neurosurgery and is actively practicing. One Reviewer is board certified in neurosurgery 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 FoundationOne gene test. Based on the available documentation, this patient has demonstrated resistance to therapy. 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 both reliable and 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. In addition, a 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. All told, the FoundationOne gene test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the FoundationOne gene test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: One reviewer is board certified in and is actively practicing. One Reviewer is board certified in and is actively practicing. One Reviewer is board certified in 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 reimbursement for the Decipher Gene Expression test. The National Comprehensive Cancer Network (NCCN) recommends molecular profiling post-biopsy for patients with low or favorable intermediate risk disease. Such testing may include the Decipher tumor based molecular assay. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups. Patients with clinically localized disease may consider the use of tumor-based molecular assays to guide treatment decision making. For these reasons, the Decipher Gene Expression test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: One reviewer found that the Decipher Gene Expression test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Two of the three reviewers determined that the services at issue were likely to be more beneficial for evaluation 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 sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 acupuncture services. Findings: patients who present with chronic cervical pain, when acupuncture was added to conventional treatment, it relieved pain better and electroacupuncture relieved pain even more. Regarding headaches, acupuncture is an effective and valuable option for patients suffering from migraine or frequent tension-type headaches. The acupuncture notes reported only temporary pain relief. It is unclear whether the patient was instructed in self-care measures (home exercise program, proper biomechanics, etc.). This in order to stimulate self-reliance and avoid dependency on passive care (i.e. acupuncture, massage, etc.). After acupuncture sessions, no specific; measurable; sustained; significant or objective functional improvement in activities of daily living was documented. Therefore, based on the lack of documentation demonstrating medication intake reduction; work restriction reduction; or activities of daily living improvement directly attributable to prior extensive acupuncture; any additional acupuncture is not medically necessary.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 oriental 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the preconception genetic testing ( molecular pathology procedure, Level 7). According to the American College of Obstetricians and Gynecologists (ACOG), expanded carrier screening panels offered by laboratories typically include options to screen from 5-10 conditions to as many as several hundred conditions. Ethnic-specific, panethnic, and expanded carrier screening are acceptable strategies for prepregnancy and prenatal carrier screening. This patient is noted to be of Ashkenazi Jewish descent. Applying the recommendations from the ACOG, the preconception genetic testing ( molecular pathology procedure, Level 7), was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the preconception genetic testing (molecular pathology procedure, Level 7), was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were likely to be more beneficial for evaluation 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 obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology with subspecialty certification in maternal and fetal medicine and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology 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 reimbursement for magnetic resonance imaging (MRI) of the breast. The Health Plan has denied this request indicating that the service at issue was not medically necessary for treatment of the enrollees breast calcifications. At issue in this case is whether the magnetic resonance imaging (MRI) of the breast was medically necessary for treatment of the enrollees medical condition. Contrast enhanced breast MRI is a highly sensitive (greater than 90%) examination which has clear indications and can identify abnormalities that are occult on mammography and ultrasound. Indications for breast MRI include high risk screening; new diagnosis of breast cancer to evaluate for additional sites of disease; patients with positive margins after lumpectomy; evaluation of response to chemotherapy prior to surgery; evaluation for breast cancer recurrence; evaluation of metastatic cancer of an unknown primary source and lastly MRI may be used when mammographic/sonographic findings are inconclusive. The patient does not meet any of the above indications for breast MRI. She is not considered high risk and her mammogram and ultrasound were not inconclusive, as she underwent stereotactic biopsy to evaluate calcifications. The mammographic and sonographic findings should be fully evaluated and biopsy performed under mammographic or sonographic guidance as indicated. MRI is not appropriate to use as a problem solving tool in this setting. In this case, MRI was not medically necessary.Final Result: The reviewer determined that the service at issue 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 diagnostic radiology 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 lumbar spinal fusion surgery. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees central posterior annular tear.At issue in this case is whether the requested lumbar spinal fusion surgery is medically necessary for treatment of the patients medical condition.The patient is diagnosed with chronic low back pain with no dermatomal/myotomal symptoms or findings of a lumbar radiculopathy (Ropper AH et al). The patient has no symptoms of neurogenic claudication and there is no documentation of failed conservative management in the past three to six months. There is no documented cognitive behavioral therapy for the nicotine addiction. There is no evidence of spondylolisthesis instability. There is no correlation of imaging for a clinical condition, and no localizing features of pain or signs/symptoms to implicate the L4-5 or the L5-S1 level as the pain generator.The Milliman Care guidelines criteria for lumbar fusion for each level require: low back pain with radiculopathy that has not responded for three to six months of conservative management including documented physical therapy, injections, NSAIDS/analgesics, home exercise program, imaging correlates with clinical findings, completion of a cognitive behavioral rehabilitation program, documentation of being nicotine free for at least 6 weeks, tumor/infection/trauma, progressive nerve compression with acute neurologic deficit. The patient does not meet any of the criteria for a two level L4-5/L5-S1 spinal fusion; therefore, the proposed surgery is not medically necessary. Final Result: The reviewer determined that the requested procedure 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 29-year-old female enrollee has requested authorization and coverage for facial feminization surgery. The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollees gender dysphoria. At issue in this case is whether the requested facial feminization surgery is medically necessary for treatment of the patients behavioral health condition. Medically necessary gender affirming/confirming surgical procedures are described in section XI of the WPATH standards of care. These procedures include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient; including, for example, skin flap hair removal; scrotoplasty and penile and testicular prostheses, as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. The medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. These procedures are reconstructive surgeries. The patient has a documented history of gender dysphoria, has been on cross gender hormone therapy, and has had other gender confirming surgeries specifically vaginoplasty and orchiectomy. Facial feminization surgery (FFS) would provide reconstructive surgical services for an abnormality as a result of the disorder of gender dysphoria. The outcome of reconstructive surgery would be enhancement of psychological and social functioning. Based on the documented history of gender dysphoria and evidence of the medical necessity of FFS, the requested facial feminization surgery is medically necessary.Final Result: The reviewer determined that the requested procedures 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested reimbursement for the genetic testing (CPT 81229). The American College of Medical Genetics, the American Academy of Pediatrics, and the American Academy of Neurology all recommend chromosome microarray as the first-line in the evaluation of children with global development delay. Moreover, there is ample data in the published medical literature demonstrating the clinical utility of chromosome microarray in the evaluation of young patients with global developmental delay or autism spectrum disorder. Given this support, the genetic testing (CPT 81229) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genetic testing (CPT 81229) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genetic testing (CPT 81229) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics and are actively practicing. Physician reviewer 1 is board certified in pediatrics and neurology with special qualification in child neurology and are actively practicing. Physician reviewer 1 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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.