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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx melanoma assay for evaluation of the enrollees cutaneous melanoma. Findings:  The 3 physician reviewers found that the DecisionDx melanoma assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. The test is currently not standard of care, has not been demonstrated to provide a beneficial effect on health outcomes. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx melanoma assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees moderate to severe plaque psoriasis. Findings:  The physician reviewer found that this patient has reportedly tried and failed treatment with topical steroids, methotrexate and Enbrel. As noted in the medical literature, Enbrel and Humira are within the same biologic class with the same mechanism of action. As the patient has already failed a six month course of treatment with Enbrel, it is not reasonable to require that he also fail therapy with Humira prior to coverage of Otezla. In addition, Otezla is a U.S. Food and Drug Administration (FDA) approved oral medication for the treatment of psoriasis. Otezla does not require routine laboratory monitoring due to its safety profile. Given that the patient has already failed two preferred systemic agents for psoriasis, the request for Otezla is supported as medically necessary for treatment of the patients plaque psoriasis. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested authorization and coverage for a transcutaneous electrical nerve stimulator (TENS) unit for treatment of the enrollees migraines. Findings:  The physician reviewer found that a review of the current medical literature does not support the requested TENS unit for treatment of this patients medical condition. Specifically, a TENS unit is not medically necessary as the effectiveness of a TENS unit for migraines has not been established in the medical guidelines and studies. Moreover, the patient has not reportedly been treated with standard first-line therapies including medications that have been demonstrated to be effective in managing migraine headaches. All told, the requested TENS unit is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: An enrollee has requested authorization and coverage for Orthovisc injections for the bilateral knees for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the current medical evidence supports the requested services in this clinical setting.  As noted by colleagues, European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) treatment algorithm recommends intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs (NSAIDs).  The authors noted that there is evidence demonstrating that intra-articular hyaluronic acid injections are beneficial for the treatment of patients with knee osteoarthritis. Colleagues performed a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other nonoperative treatment modalities for knee osteoarthritis. Per the authors, the evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. In sum, there is sufficient support for the requested services in this clinical setting. All told, Orthovisc injections for the bilateral knees 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for drug-induced sleep endoscopy for evaluation of his obstructive sleep apnea.  Findings: The physician reviewer has found that the request for a drug-induced sleep endoscopy is not medically necessary for evaluation of the patients medical condition. The medical records submitted for review does not support the requested study. There is no documentation of daytime hypersomnia which is a cornerstone for a diagnosis of sleep apnea or that the patient is obese. There is no diagnostic polysomnogram provided to support a diagnosis of sleep apnea. In addition, there is no Epworth Sleepiness score or documentation of an abnormal Mallampati score noted. Moreover, there is no evidence of any primary sleep disorder or documentation that the patient is at a high risk for sleep apnea. For the reasons provided, the requested services are not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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 pulmonary disease 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 parent of an enrollee has requested reimbursement for residential treatment center services provided for treatment of enrollee's behavioral health condition. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. Based on these guidelines, the RTC services provided were medically necessary for treatment of this patients medical condition. The patient was at moderate risk of harm (score 3). The patients functional status demonstrated serious functional impairment (score 4) as the patient consistently has disruptive relationships with others. With this behavior, it is unlikely that the patients mother could have managed the patient as an outpatient. It would have been likely that the patient would have ended up in an inpatient psychiatric facility which would be more expensive than a RTC. The patient had significant co-morbidity (score 3). The patients recovery environment was moderately stressful (score 3), his environmental Support was supportive (score 2), and the patient demonstrated poor response to treatment (score 4). The patient was adversarial and no engaged in treatment (score 4) as he was frequently physically aggressive with staff which caused him to be restrained on many occasions. This composite score of 23 supports treatment at the RTC level of care.  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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for compression gloves for treatment of the enrollees hand pain. Findings:  The physician reviewer found that the treatment and management of osteoarthritis includes non-pharmacologic, pharmacologic, and surgical options. Therapies are aimed at improving the pain and functional restriction that characterizes this disease. Splints are commonly used for patients that have pain at the base of the thumb. However, there is no indication for compression gloves for the treatment of osteoarthritis of the hands. In this case, the documentation supports the patient has a diagnosis of primary osteoarthritis of the hands, and she has been prescribed compression gloves for the treatment of her condition. The use of compression gloves or garments is indicated when there is a disruption of lymph or blood flow in a part of the body or swelling caused from lymphedema. Although the patient has a history of breast cancer with a mastectomy that would increase the risk for lymphedema of the upper extremity, there is no documentation to support that this is what the compression gloves are being requested for.  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 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 parent of a male enrollee has requested authorization and coverage for procedure codes 21143 for Lefort I osteotomy, and 21085 for impression and preparation for an oral surgical splint for treatment of the enrollees dentofacial deformity.  Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested procedures in this clinical setting. Based on the documentation and the photographs submitted, this patient has a well-documented maxillofacial skeletal deformity that cannot be corrected with orthodontics alone. This patient has significant overjet and overbite making it very difficult for the patient to chew his food. The proposed procedures would result in improved musculoskeletal and dento-osseous relationships and improvement in mastication. For these reasons, procedure codes 21143 for Lefort I osteotomy, and 21085 for impression and preparation for an oral surgical splint are medically necessary for treatment of this patients dental condition. With regards to whether the requested procedures are considered reconstructive in nature, the records reveal that this patient has well-documented maxillofacial skeletal deformity.  The etiology of maxillofacial skeletal deformities may be either congenital or acquired. Deformities may be evident at birth or may manifest during subsequent growth and development, creating functional and degenerative problems. The requested procedures will improve function and create a more normal appearance in this patients case. It will also result in improved musculoskeletal and dento-osseous relationships. Moreover, these procedures will allow improvements in mastication. All told, procedure codes 21143 for Lefort I osteotomy, and 21085 for impression and preparation for an oral surgical splint are reconstructive in nature for the treatment of this patients dental condition. Final Result: The reviewer determined that the requested procedures are medically necessary and are reconstructive in nature for treatment of the patients dental condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections for treatment of the enrollees chronic migraine. Findings:  The physician reviewer found that as per the International Headache Society Classification of Headache Disorders, chronic migraine is defined as greater than 15 days per month for greater than three months, headache not attributable to another disorder, at least two characteristics of unilateral, pulsatile, moderate to severe in intensity, or aggravation by or causing avoidance of routine physical activity. Additionally, there must be one characteristic of nausea and/or vomiting, photophobia and phonophobia. Botox is a tool in the management of chronic migraine which has shown effectiveness in the PREEMPT trials. However, there were significant criticisms of the trails outcomes including absolute gain of headache-free days, primary efficacy end point of PREEMPT 2, which was only 2.3 days on average over a 28 week period, high placebo effect, and the trials enrolled a majority of subjects with concomitant medication overuse headache possibly confounding the results. In a study by colleagues, they compared Topamax, Botox, and placebo in a double blind study. The authors concluded OnabotulinumtoxinA and topiramate demonstrated similar efficacy in the prophylactic treatment of chronic migraine. In this patients case, there is a lack of support for the requested Botox therapy for treatment of her headaches. The clinical evidence and the limitations in the PREEMPT trials suggest that Botox is not superior to alternative oral therapies. Moreover, there is insufficient documentation to support the patient has failed other drug classes which are potentially equally as effective.  The patient has a history of kidney stones.  However, this is not a contraindication for future use of topiramate in the appropriate setting and/or with adequate monitoring.  As such, Botox injections for treatment of her medical condition is not medically necessary. 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 neurology with expertise in episodic and chronic migraine disease 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 platelet-rich plasma injection provided for treatment of the enrollees posttraumatic osteoarthritis. Findings:  2/3 of the physician reviewers found that current, evidence-based guidelines do not recommend platelet-rich plasma injection for ankle or foot conditions, with higher quality evidence showing this treatment to be no better than placebo. In their review of 17 randomized and two quasi-randomized trials with 1088 participants. Colleagues concluded that overall, and for the individual clinical conditions, there is currently insufficient evidence to support the use of platelet-rich therapies for treating musculoskeletal soft tissue injuries. This patient presented with persistent lateral ankle pain that limited his activity level. He was status post right ankle lateral ligament reconstruction, tibial exostectomy, and talus osteophyte excision. He had been diagnosed with right ankle posttraumatic osteoarthritis. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has not been submitted. There is insufficient evidence to support the use of platelet-rich plasma therapies in the ankle. There is no compelling rationale presented to support the services at issue over standard therapy for this patients residual ankle pain. Therefore, the platelet-rich plasma injection provided was not likely to have been of greater benefit than other treatment alternatives. Final Result: 2/3 of 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 parent of an enrollee has requested reimbursement for extraction of two teeth (numbers 1 and 16) and anesthesia provided for the treatment of the enrollee, who reported jaw pain and headache. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The records documented that teeth numbers 1 and 16 were impacted. There was inadequate space for ideal eruption and maintenance of oral hygiene. Left untreated, the retained third molars were likely to have resulted in disease with dental and medical consequences. Studies have demonstrated that removal of wisdom teeth when a patient is younger is prudent and results in decreased complications and improved recovery. Given the patients age, anxiety and nature of the procedure, performance of the procedure with anesthesia was medically appropriate.  All told, extraction of two teeth (numbers 1 and 16) and anesthesia provided were medically necessary for the 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 oral and maxillofacial 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.