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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for requested Adderall ER 20 mg capsules (dextroamphetamine-amphetamine extended release 20 mg capsules) taken as one capsule twice daily (quantity 60 capsules per month). In this case, the patient has a longstanding diagnosis of attention-deficit/hyperactivity disorder (ADHD) that has been treated with a psychopharmacological medication, Adderall ER, dosed at 20 mg twice daily. The records document that the patient has been stable on this dose and without any side effects for several years. As noted in the peer-reviewed medical literature, stimulants are considered first-line treatment options for patients with ADHD. Per the U.S. Food and Drug Administration (FDA) approval, the maximum dose of Adderall ER daily is 60 mg per day. Although a dose of 20 mg daily of Adderall ER is the standard recommended dosage, treatment guidelines indicate that dosing should be tailored to each patients needs and their response to the medication. Adderall ER has a duration of action from 10 to 12 hours, which is inadequate for many patients. The records establish that this patient has been titrated to a dose of 20 mg twice per day as the lowest effective dosage established more six years ago and continues to benefit without any adverse effects. For these reasons, the requested Adderall ER 20 mg capsules (dextroamphetamine-amphetamine extended release 20 mg capsules) taken as one capsule twice daily (quantity 60 capsules per month) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested Adderall ER 20 mg capsules (dextroamphetamine-amphetamine extended release 20 mg capsules) taken as one capsule twice daily (quantity 60 capsules per month) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication dosage is 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for office visit, transvaginal ultrasound, and/or the pelvic non-obstetrical ultrasound. The records provided for review support a diagnosis of female infertility. The patients treatment plan included ovulation induction with letrozole followed by intrauterine insemination with donor sperm. This treatment plan is consistent with the recommendations from the American College of Obstetricians and Gynecologists (ACOG). The patient was treated with services such as the administration of letrozole, close clinical follow-up with office visits, and ultrasound to evaluate follicular maturation. As noted in the ACOG recommendations, the close clinical follow-up with office visits, pelvic non-obstetrical ultrasound, and transvaginal ultrasound were appropriate to treat this patients infertility. The medical literature also supports use of letrozole in the treatment of female patients with infertility (Legro, et al.). All told, the office visit, transvaginal ultrasound, and the pelvic non-obstetrical ultrasound were medically necessary for treatment of 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 obstetrics and gynecology 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 DecisionDx-Melanoma genetic testing. Based on the patients American Joint Committee on Cancer (AJCC) stage alone, she had five-year and ten-year melanoma survival rates of 99% and 98%, respectively. The gene expression profiling (GEP) test was subsequently performed and yielded a Class 1a score. Based on the GEP score alone, the patients five-year melanoma specific survival would be as high as 100%, signifying a better prognosis for the patient. At this time, there is a lack of evidence indicating that this information can be used in a clinically meaningful way to benefit the patient, namely, how much less follow-up or screening would be safe for the patient given her current AJCC stage combined with GEP score. In this case, the patient would be a candidate for a sentinel lymph node biopsy, which is recommended for additional staging under National Comprehensive Cancer Network (NCCN) guidelines. The use of the test at the current time is not endorsed and it is not incorporated into the most widely used treatment and management protocols. Therefore, DecisionDx-Melanoma genetic testing was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma genetic testing at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a replacement CPAP machine and accessories. The current medical evidence does not support the requested equipment in this clinical setting. The records document that the patient had an AHI of 2.1. Based on the home sleep study, he does not meet the criteria for obstructive sleep apnea. In order to establish the diagnosis of obstructive sleep apnea, AHI should be greater than 5. Based on the patients home sleep study in 2019, obstructive sleep apnea is not documented. A new sleep study showing an AHI greater than 5 will be required to support the medical necessity of a new CPAP machine. Therefore, the requested replacement CPAP machine and accessories are not medically necessary for the treatment of this patient. 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 internal medicine with sub-specialty certification in sleep 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox injections of bilateral toes. Findings:  The physician reviewer found that Dystonia is a movement disorder involving muscle contractions causing abnormal, repetitive movements and/or postures. Dystonia is often initiated or worsened by voluntary action and associated with overflow muscle activation. Per the records, this patient has been diagnosed with focal dystonia. Botox injection therapy is the treatment of choice for adults with focal dystonia.  The current medical evidence supports the safety and efficacy of Botox injections for the treatment of focal dystonia. Therefore, Botox injections of bilateral toes are 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left hip replacement surgery.Katz and colleagues have noted that hip and knee osteoarthritis are highly prevalent and disabling. Education, exercise, and weight loss are cornerstones of management, complemented by NSAIDs (for patients who are candidates), corticosteroid injections, and several adjunctive medications. For persons with advanced symptoms and structural damage, total joint replacement effectively relieves pain. Haynes and colleagues concluded that obesity is associated with a significantly younger age at the time of primary total hip arthroplasty and that obese patients are likely to experience a higher rate of peri-operative complications. Gritsyuk and colleagues concluded that while functional ability increased in all patients who had total hip arthroplasty, it was significantly lower in Class 3 (BMI  40) patients (with morbid obesity). Therefore, patients with Class 1 (BMI 26-34) and Class 2 (BMI 35-39) obesity should be conceptionally distinguished from Class 3 patients in the decision-making process for a primary total hip arthroplasty because of the less favorable functional and mental health improvement in those with morbid obesity (Class 3).In this case, the patient is noted to have been seen by an orthopedic provider who recommended weight loss prior to a left total hip replacement. Upon another orthopedic visit, her body mass index was noted at 46.2 and she was noted to be at high risk for surgery. The submitted documentation does not reflect that the patient has a body mass index that is less than 40, and there have been no updated examinations that provide an updated weight to corroborate her body mass index. There is limited published, large-scale, long-term peer-reviewed literature that shows total hip arthroplasty to be an effective and/or safe treatment in the setting of morbid obesity. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Under these circumstances, the requested left hip replacement surgery is not medically necessary to treat this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopaedic 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

Findings:  The physician reviewer found that The patient has requested reimbursement for monitored anesthesia care provided during a colonoscopy. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that, anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are American Society of Anesthesiologists (ASA) Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine.  Wernli and colleagues reported that the use of anesthesia service was associated with a 13% increase in the risk of any complication within 30 days and was associated specifically with an increased risk of perforation, hemorrhage, abdominal pain, complications secondary to anesthesia, and stroke. The authors further report that for most outcomes, there were no differences in risk with anesthesia services by polypectomy status, however, the risk of perforation associated with anesthesia services was increased only in patients with a polypectomy. In this case, the patient underwent a routine screening colonoscopy. The patient did not have any significant heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. There was no detailed description of previous history of difficulties with anesthesia or sedation with past colonoscopies documented in the submitted records. The patient had an ASA classification score of 2 and had a Mallampati airway grade of 1. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the service at issue was not medically indicated. Therefore, monitored anesthesia care provided during the patients colonoscopy was not medically necessary for the treatment of this patient.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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a LINX procedure. There is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. The American College of Gastroenterology (ACG) guidelines for the management of reflux disease note that while the LINX Reflux Management System has been approved by the U.S. Food and Drug Administration (FDA), more data is required before widespread usage can be recommended. Researchers concluded, Long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Likewise, medical literatures reported that the long-term safety and efficacy of LINX  both alone and compared to current GERD therapies  remain to be determined. Researchers report that severe dysphagia requiring endoscopic intervention was more frequent with LINX than with surgical fundoplication. Researchers found that erosion of the LINX device is an important but rare complication to recognize. The authors noted that LINX has significant potential adverse effects and may be associated with poorer outcomes. Therefore, a LINX procedure is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services 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 internal medicine with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services. Findings:  The physician reviewer found that he American Society for Gastrointestinal Endoscopy (ASGE) guidelines for sedation and anesthesia in gastrointestinal endoscopy concluded that, the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events (Early, et al.). The ASGE guidelines recommend anesthesia provider-administered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. A review study performed by Wernli and colleagues found that the use of deeper levels of anesthesia was associated with a 13% increase in complications including bowel perforations. In this case, the patient underwent a routine colonoscopy. The patient did not have any significant  lung, kidney, or liver disease. The patient has a previous history of supraventricular tachycardia (SVT) which was treated with ablation, at the time of his evaluation he was found to be asymptomatic in normal sinus rhythm.  There was no documentation of a  history of alcohol or substance abuse. There was no detailed description of previous history of difficulties with anesthesia or sedation with past colonoscopies documented. The patient was given an American Society of Anesthesiologists (ASA) classification score of 2 and had a Mallampati airway grade of 2. The ASGE guidelines do not support the use of monitored anesthesia care in a patient who does not have significant health conditions nor airway concerns. The guidelines suggest there is high quality evidence to support the use of mild-to-moderate sedation in healthy uncomplicated endoscopy procedures, which was the case with this patients procedure. Based on these findings, the anesthesia services were not medically necessary for this patient. Final Result: The reviewer determined that the services at issue 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for morphine sulfate (MS) Contin immediate release 150 mg. Findings:  The physician reviewer found that determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The authors further report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  Manchikanti and colleagues recommend the establishing of the medical necessity of opioids on appropriate physical diagnosis and psychological diagnosis, appropriate imaging, and psychological status to collaborate with the patients subjective complaints, along with establishing average moderate-to -severe pain and/or disability. In this case, the patient is on high dose opioid therapy. The records note diagnoses of chronic pain, myopathy, and HIV infection.   The patients care team, including pain management, has not recommended an increase in opioid therapy, and the patients provider has declined to prescribe immediate release morphine. The records note concerns regarding unsafe drug interactions with the patients prescribed clonazepam. Given the lack of support from any of the patients providers to switching the patient to the immediate release formulation of morphine, the requested medication is not medically indicated. Therefore, MS Contin immediate release 150 mg 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 anesthesiology with sub-specialty 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.