Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injection series in the left knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injection series in the left knee is 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Gel-One injection for the left knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient reported that relief from injections in the right knee had staved off a right total knee arthroplasty for ten years. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, along with the good prior response to viscosupplementation, the requested service is medically indicated. Therefore, a Gel-One injection for the left knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Molecular Pathology.Findings:  The physician reviewer found that In all cases, the genetic mutations that are present with pancreatic cancer can provide prognostic significance and can help direct therapy. Mutational analysis is part of the algorithms that are included within the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for pancreatic cancer. According to the NCCN guidelines, germline testing is recommended for any patient with confirmed pancreatic cancer, using comprehensive gene panels for hereditary cancer syndromes. The guidelines recommend genetic counseling for patients who test positive for a pathogenic mutation or for patients with a positive family history of cancer, especially pancreatic cancer, regardless of mutation status. For example, BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. NCCN guidelines also state that tumor/somatic gene profiling is recommended for patients with locally advanced/metastatic disease were candidates for anticancer therapy to identify uncommon mutations. The guidelines state that providers should consider specifically testing for actionable somatic findings including, but not limited to fusions (ALK, NRG1, and TRK, ROS 1), mutations (BRAF, BRCA1/2, HER2, KRAS, PALB2), and mismatch repair (MMR) deficiency. In this case, a Guardant mutational analysis was ordered to inform next steps in therapy. The patient will be offered something off-label or a phase I/II clinical trial, but with the results from molecular profiling there may be a rational selection of the next regimen. Therefore, the requested Molecular Pathology is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Findings: Two out of three physician reviewers found that the requested molecular pathology is likely to be more beneficial than any other available standard treatments for the patients medical condition.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in medical oncology, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency, first vein treated left greater saphenous vein and, stab phlebectomy of varicose veins, one extremity, more than 20 incisions. Findings:  The physician reviewer found that the recommend compression therapy for patients with symptomatic varicose veins, and endovenous thermal ablation for treatment of an incompetent great saphenous vein. In this case, the submitted records noted paresthesias affecting the left foot and toes, possibly neuropathic in nature. The documentation did not describe symptoms within the distribution of the veins to be treated, multiple episodes of superficial thrombophlebitis, or mention phlebitis. The records did not reflect trials of conservative therapy for varicose veins or edema. In this clinical setting, given the lack of reported symptoms in the distribution of veins to be treated and lack of documentation showing conservative efforts to treat the patients edema, the requested services are not medically indicated. Therefore, endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency, first vein treated left greater saphenous vein and, stab phlebectomy of varicose veins, one extremity, more than 20 incisions are not medically necessary for the treatment of this patient.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 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: The patient has requested authorization and coverage for fibroid removal surgery and corresponding full hospital stay. Uterine fibroids are typically benign tumors in the uterus that can cause heavy vaginal bleeding or bulk symptoms of pain and pressure. Uterine myomectomy is a procedure performed to remove fibroids while leaving the uterus intact. This treatment is effective for managing bulk symptoms associated with fibroid uteruses. Surgical intervention with hysterectomy or myomectomy are the only options for treatment of bulk symptoms. In this case, uterine myomectomy is consistent with the current standard of care for the removal of symptomatic fibroids. Given the size of this patients fibroid measuring 6 cm, the procedure will be performed via laparotomy. Typically, blood loss is minimal, and a patient can be discharged home after a period of observation. The records do not include documentation to support full admission following the fibroid removal surgery. Therefore, the requested fibroid removal surgery is medically necessary while a corresponding full hospital stay is not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox per axilla injected every three to four months. Findings: Hyperhidrosis is a dermatologic condition that affects a patients quality of life due to the bodys inability to thermoregulate, which results in excess sweating. Per the records reviewed, this patient has a longstanding history of hyperhidrosis. During this time, they have been treated with both topical and oral medications to control the disease without substantial improvement. They continue to experience issues with stress and anxiety in work and social situations related to their hyperhidrosis. Their provider has recommended treatment with Botox. According to a study, Botox can serve as a safe and effective treatment option for focal hyperhidrosis. Moreover, the authors commented that oral systemic agents are reserved for treatment-resistant cases or for generalized hyperhidrosis. This patient has been treated with oral and topical therapies without adequate control of their symptoms. For these reasons, the requested Botox per axilla injected every three to four months is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology 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 left knee arthroscopy. The records provided for review document that this patient has magnetic resonance imaging (MRI) evidence of advanced tricompartmental osteoarthritis of the left knee, full thickness chondral loss of the medial compartment, and a likely degenerative tear of the body of the medial meniscus, which is not displaced. There is evidence of tricompartmental osteophytosis. The provider has recommended arthroscopy. A review of the current medical literature pertaining to arthroscopic debridement of osteoarthritis of the knee reveals mixed findings. Researchers noted that, Over the long-term, patients who undergo knee arthroscopy versus those who receive conservative management strategies do not have important benefits in pain or function. The authors concluded that of the 13 randomized controlled trials and 12 observational studies assessed, the pain relief post knee arthroscopy is small and short-lived. Researches reported that knee arthroscopy for patients with degenerative knee is limited in time and absent at one to two years after surgery. For these reasons, the requested left knee arthroscopy is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a coronary artery calcium screen provided by Central Coast Radiology Associates Inc. In this case, the patients ten-year atherosclerotic cardiovascular risk level was intermediate, at five to ten percent, and the records did not document that the patient was on statin therapy for hypercholesterolemia. Under the American Heart Associations guidelines on the management of blood cholesterol, a coronary calcium score of 0 would reclassify the patient as low risk for cardiovascular disease. In this clinical setting, the service at issue assisted the provider in reclassifying the patients risk level and obviated the need for statin therapy. Therefore, the coronary artery calcium screen provided by Central Coast Radiology Associates Inc. was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the coronary artery calcium screen provided by Central Coast Radiology Associates Inc. at issue was 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 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 overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 authorization and coverage for Xeljanz 5 mg tablets. Alopecia areata is an autoimmune disorder that causes hair loss in the scalp and can progress to alopecia universalis. This patient has a longstanding history of alopecia areata and he demonstrated worsening of the disease in the last few years. In 2019, he was diagnosed with alopecia areata universalis. Xeljanz treatment was initiated at that time, and he exhibited significant improvement. Due to illness and concerns about immune suppression in the light of COVID-19, the patient ceased therapy. On follow-up, the provider noted that the patient has lost the progress he made with Xeljanz. Upon review of the current peer-reviewed medical literature, it has been noted that aggressive treatment is reserved for patients with a higher percentage of surface involvement. This patient has progressed to alopecia areata universalis, which supports aggressive treatment. Strazzulla and colleagues recommend topical and oral steroids, as well as JAK inhibitors for patients with greater than 50% scalp involvement. This patient previously failed standard therapies. He has a history of significant improvement while on Xeljanz, which is now waning after being off of the medication for about several months. All told, the requested Xeljanz 5 mg tablets are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Xeljanz 5 mg tablets are 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 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. 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 LINX procedure. There is a lack of evidence in current medical literature supporting the safety and efficacy of the LINX procedure. Skubleny and colleagues note that Nissen fundoplication (LNF) is the gold-standard surgical treatment for GERD. The authors further note that while the LINX magnetic sphincter augmentation (MSA) appears to be an effective treatment for GERD, long-term comparative outcome data past one year is needed in order to further understand its efficacy. Sheu and colleagues note that severe dysphagia requiring endoscopic intervention is more common with MSA over LNF. In this clinical setting, given the providers recommendation against a LINX procedure due to associated potential adverse effects and poor outcomes, the requested service is not medically indicated. Therefore, a LINX procedure is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for esophageal pH monitoring.Rumination syndrome is a functional gastrointestinal disorder characterized by effortless postprandial regurgitation. Combined 24-hour pH-impedance (pH-MII) and manometry can be used to diagnose rumination syndrome in children and to distinguish it from GERD. In this case, the patient had regurgitation several times per day consistent with rumination syndrome, in which postprandial regurgitation is common. pH monitoring reveals a distinct pattern in rumination syndrome versus refractory GERD, and provides objective data for diagnosis. The distinction is important because antisecretory therapy can make rumination symptoms worse, and rumination can be associated with nausea. For these reasons, the pH monitoring at issue is supported as medically necessary for the diagnosis of this patients regurgitation symptoms. Therefore, the esophageal pH monitoring at issue was medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for botox injections.Findings: Two out of three physician reviewers found that the requested botox injections are not likely to be more beneficial than any other available standard treatments for the patients medical condition.There is not sufficient support for the requested services in this clinical setting. Botulinum toxin injection (botox) is not approved by the U.S. Food & Drug Administration (FDA) for the treatment of gastroparesis. At this time, there is not sufficient scientific evidence to support the safety and efficacy of botox injection for the treatment of gastroparesis in children. Clinical practice guidelines adopted by the American College of Gastroenterology (ACG) state that botulinum toxin injection into the pylorus is not recommended as a treatment for gastroparesis. The safety and long-term efficacy of pyloric botox injections in treating gastroparesis in children is not established or proven. There is no well-structured scientific evidence (i.e. randomized prospective clinical trials) supporting the safety and long-term efficacy of this treatment in children with gastroparesis. Accordingly, the requested botox injections are not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in pediatrics, with subspecialty certification in pediatric gastroenterology, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.