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

Nature of Statutory Criteria/Case Summary: A 56-year-old female enrollee has requested reimbursement for the occipital nerve blocks, and nerve testing for treatment of the enrollees fatigue, lightheadedness, and skin hypersensitivity.  Findings:  The physician reviewer found that per the medical records, the patient presented with hypersensitivity of skin, photophobia, hyperosmia, hyperacusis as well as lightheadedness when moving from a squatting position. The patient also had a complaint of migraine headaches. However, the medical records do not document use of traditional migraine headache therapies. Furthermore, there is a paucity of current studies which suggest that the use of occipital nerve blocks will improve abnormalities of the autonomic nervous system. There is a lack of documentation that the patient has greater occipital neuralgia. Furthermore, there is no literature which suggests that occipital nerve blocks can treat the patients symptoms. Given these findings, the occipital nerve blocks, and nerve testing were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the occipital nerve blocks, and nerve testing were 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 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 neurology and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology 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

A enrollee has requested authorization and coverage for celecoxib. Findings:  The physician reviewer found that the medical necessity of celecoxib has not been established. Standard of care in this setting suggests topical heat, exercise and nutritional supplementation may be beneficial in patients who have dysmenorrhea. Management recommendations for other treatment options including Depo Provera, Lupron and laparoscopy (to evaluate for endometriosis) which are documented in the treatment notes as having been discussed. A trial of Lupron was also recommended to confirm a diagnosis of endometriosis. Hysterectomy, which constitutes ultimate management of both dysmenorrhea and/or endometriosis, was also discussed. Review of the scientific literature demonstrates that large studies have been shown NSAIDs to be very helpful in the management of pain with primary dysmenorrhea. Studies have demonstrated that all classes of NSAIDs have worked equally well to control the pain associated with dysmenorrhea. The use of a Cox 2 inhibitor like celecoxib over other NSAIDs has not been shown to be more efficacious in this setting. Furthermore, if the patient has an ulcer or upper gastrointestinal disease then she would not be a candidate for any of the NSAIDs. In this case, the patient states that she cannot take other NSAIDs because of stomach issues and bleeding. As such, celecoxib is contraindicated as is any other NSAID. For the reasons stated above, the requested celecoxib is not medically necessary for treatment of 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization psychiatric substance abuse level of care services.  Findings:  The physician reviewer found that submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes indicate that the patient was cooperative in treatment. The patient had minimal treatment in 2017. On admission to the partial hospitalization program, the patient appeared motivated for treatment and was not experiencing withdrawal symptoms, medical problems, or any serious psychiatric symptoms that required intensive daily treatment. She was motivated for treatment with mention of insight into her illness as well as documentation of her knowledge of skills to maintain sobriety. The supplied documentation does not indicate that she was having severe mood swings or other severe psychiatric symptoms. The American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services can assist in determining necessary level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation. With regards to functional status, the records support a score of 2 to 3 due to the loss of custody of her child and continued substance use. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability. With regards to level of stress of the recovery environment, the records support a score of 3 due to no mention of a stressful recovery environment. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 3 due to lack of treatment during the prior 12 months. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Thus, the patient has a composite score of 15 to 16. This score correlates with services in a community-based outpatient clinic setting. Thus, the patient could have been treated in a less restrictive setting. In sum, partial hospitalization psychiatric substance abuse level of care services were not medically necessary for the treatment of 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for destruction by neurolytic agent (CPT 64640 x 2) and chemodenervation of eccrine glands (CPT 64650 x 2). Findings:  Two of the three physician reviewers found neuralgia is a type of neuropathic pain. Attacks can either be spontaneous or provoked by direct stimulation or palpation of other trigger point zones. Occipital neuralgia specifically refers to pain and/or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. This patient has been diagnosed with occipital neuralgia on examination. Another key element to the diagnosis is response to occipital nerve blocks. Per the records, this patient did not sustain permanent relief following the injection. There is data to suggest that oral agents, such as carbamazepine, gabapentin, and tricyclic antidepressants, can be effective. On 3/07/18, the patient reported that gabapentin was effective. All told, the requested destruction by neurolytic agent (CPT 64640 x 2) and chemodenervation of eccrine glands (CPT 64650 x 2) are not likely to be more effective than other treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in neurology 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: A enrollee has requested reimbursement for the air and associated ground ambulance transportation services. She suffered a significant, life-altering, hemorrhagic stroke, which left her with severe dysphagia, right-sided weakness and left-sided hemi-neglect. She was non-ambulatory and required intense physical therapy and occupational therapy. At the time of her discharge from inpatient rehabilitation she remained non-ambulatory. Her team of caregivers, in consultation with family, determined that it was not medically appropriate for her to be discharged for ongoing therapy in her home, though she also did not require continued inpatient rehabilitation services. Therefore, it was determined that the most medically appropriate way to handle her ongoing need was to have her transferred for continued, pre-arranged rehabilitation and related professional services by a home-based healthcare agency. Ground transport was contraindicated given the great time and distance involved was an estimated 2,467 miles and 36 hours for transportation. The only medically appropriate way for the patient to get to the most appropriate next phase of her ongoing care was transport by medically-configured, fixed-wing aircraft given her non-ambulatory status and need for monitoring en route. Although the transportation was not an emergency and the transportation was not to a hospital, the treatment plan was to transfer to the most medically appropriate place where the patient would be receiving pre-arranged ongoing professional services in a familiar environment and with her daughter that had received training specifically for this purpose. After review of the available medical records and documents, as well as review of applicable literature, the services were medically necessary and appropriate to treat the patients medical condition.  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 emergency 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 high intensity focused ultrasound (HIFU) noninvasive cancer treatment. Findings:  Three physician reviewers found that HIFU therapy for prostate cancer is a relatively new procedure. There is a lack of support for the services at issue for the treatment of prostate cancer. The safety and efficacy of this treatment is currently being evaluated. There is a lack of comparative clinical trials indicating that this form of treatment is superior to conventional treatment options. Therefore, HIFU noninvasive cancer treatment was not likely to have been of greater benefit 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for sympathetic nerve block. Two of the three physician reviewers found there is sufficient support for the services at issue in this clinical setting. Lumbar sympathetic nerve blocks have been studied in the interventional pain medicine and anesthesia literature and have been found to be diagnostic and therapeutic. The records note the patient failed medication and an exercise program. The scientific literature shows that lumbar sympathetic blocks are clinically useful in the diagnosis and treatment of complex regional pain syndrome. If not aggressively managed, complex regional pain syndrome can progress and may result in permanent impairment of function and/or an increase in the severity of pain. All told, the services at issue were supported by pain medicine guidelines set forth by the American Society of Anesthesiologists and other authoritative and evidence-based guidelines. As such, the services at issue were 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 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, 2 and 3 are certified in anesthesiology and pain management 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: A 32-year-old female enrollee has requested authorization and coverage for a consultation with a reproductive endocrinologist for evaluation of the enrollees endometriosis. Findings:  The physician reviewer found that based on the available documentation, it is medically necessary for this patient to be evaluated and treated as considered appropriate by a reproductive endocrinologist. A reproductive endocrinologist is appropriate to advise the patient on the different management options available, especially if a future pregnancy may be desired. Given such considerations, having the patient seeing a reproductive endocrinologist at this point could be considered analogous to having a woman with complicated medical issues seeing a maternal fetal medicine specialist, for preconception counseling, prior to attempting to conceive. All told, the requested reproductive endocrinologist consultation is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology 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 Anser ADA blood test. Findings:  Two of the three physician reviewers found there is a lack of support for the services at issue in this clinical setting. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of adalimumab or the presence of adalimumab antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there is a lack of well-controlled clinical trials to confirm that use of the Anser ADA testing leads to improved patient outcomes or quality of life as opposed to the standard methods of treatment. The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement. It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Diminished or suboptimal response to adalimumab can be managed in several ways, including shortening the interval between doses, increasing the dose, switching to a different anti-tumor necrosis factor agent (in patients who continue to have loss of response after receiving the increased dose), or switching to a non-anti-tumor necrosis factor agent based on clinical observation in lieu of Anser ADA testing. The medical evidence has not demonstrated the superior effectiveness of the services at issue in this patients case. All told, Anser ADA blood test was not 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 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: 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Myriad Genetic Laboratories test. BRCA testing guidelines recommend BRCA testing for this patient with two close relatives with ovarian cancer. However, the entire MyRisk panel includes BRCA testing plus analysis for another 26 genes. Though many of the other gene mutations are of interest and are being studied, there is a lack of data that the findings from this testing is significant to be the basis for any clinical decisions for the carriers or their family members. Such testing is not included in the guidelines from major organizations. With two young family members with ovarian cancer, the BRCA testing was appropriate in this case. However, there is a lack of data supporting the clinical utility of the remainder of the genetic testing.Thus, the BRCA portions of the Myriad Genetic Laboratories test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy and the remainder of the Myriad Genetic Laboratories test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the BRCA portions of the MyRisk genetic panel was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy and the remainder of the MyRisk panel was 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 BRCA portions of the MyRisk genetic panel was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy and the remainder of the MyRisk panel was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 reimbursement for prostate urethral lift. Findings:  Three physician reviewers found the prostate urethral lift is a novel, minimally invasive approach to treating benign prostatic hypertrophy that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials, including prospective, sham controlled, randomized studies, have shown that this treatment is safe and effective in relieving lower urinary tract symptoms without significantly compromising sexual function. However, prostatic urethral lift is an invasive procedure, and medical therapy should be exhausted prior to using an invasive procedure. Alpha blockers, 5-alpha reductase inhibitors and anticholinergic medications are standard of care in this clinical setting. Additionally, the efficacy of this treatment in the setting of failure of transurethral resection of the prostate has not been demonstrated. Thus, prostate urethral lift was not likely to have been superior over other available 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 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.