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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for laboratory testing (CPT- 82523) provided. Findings:  The physician reviewer found that DEXA measures bone mineral density, which helps in estimating fracture risk and in identifying patients who may benefit from treatment. Greenblatt and colleagues indicate that because of limitations of the DEXA scan, including radiation exposure and limited ability to predict fracture risk, BTMs, such as C-telopeptide can act as an adjunct in management of osteoporosis and are indicative of the rate of bone turnover. Szulc and colleagues state, The International osteoporosis foundation and the International Federation of Clinical Chemistry (IFCC) Bone Marker Standards Working Group have identified N-terminal propeptide of type I procollagen (PINP) and C-terminal telopeptide of type I collagen (CTX-I) in blood to be the reference markers of bone turnover for the fracture risk prediction and monitoring of osteoporosis treatment. Further, Williams and colleagues state, Unlike DEXA measurements, bone turnover markers, such as CTX, show appreciable, rapid response to changes in turnover rate, making them of great use clinically for monitoring treatment response and adherence in osteoporotic patients from the onset of treatment initiation. Therefore, laboratory testing (CPT- 82523) provided  was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings: Two out of three physician reviewers found that laboratory testing (CPT- 82523) provided was likely to have been more beneficial for the enrollee than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism. All reviewers 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:  An enrollee has requested reimbursement and prospective authorization and coverage for Monovisc injections in both knees every six months.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 three months of relief from viscosupplementation in the past. Furthermore, the patients options are limited. The alternative is bilateral total knee arthroplasties for mild osteoarthritis of both knees. Therefore, Monovisc injections in both knees every six months were and are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were and 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 Supartz injection for the left knee. Findings:  The physician reviewer found that 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 moderate to severe left knee pain due to osteoarthritis following a history of remote arthroscopic meniscectomy. The patient has tried and failed other conservative treatments, including a corticosteroid injection, 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, a Supartz 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injection (HCPCS J7325) in the right ankle.In a review by Papalia and colleagues, the authors indicate, Current evidence suggests that viscosupplementation for treatment of ankle osteoarthritis is a safe and effective method. The authors also concluded that more randomized controlled trials are needed.  Khlopas and colleagues state that viscosupplementation with hyaluronic acid has been shown to be a safe and effective method of treating osteoarthritis of the ankle. The authors reason that, For patients who have moderate to severe disease, surgery may be indicated. However, current surgical options are either associated with high rates of complications or restrict ankle range of motion (ROM). Further, the authors conclude, Early stages of the ankle osteoarthritis should be treated with [] non-surgical methods, and once the disease progresses, surgical options can be utilized. In this case, the patient has been diagnosed with severe osteoarthritis of the right ankle. The patient has tried and failed other conservative treatments. Therefore, the requested Synvisc One injection (HCPCS J7325) in the right ankle is medically necessary for treatment of the patients medical condition.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen therapy. One source of medical literature has approved hyperbaric oxygen therapy for the treatment of patients with sudden hearing loss. However, another source of medical literature include salvage hyperbaric oxygen therapy plus steroids as treatment option for use within one month of symptom onset. The records provided for review document that this patients hearing loss has fluctuated with worsening hearing loss noted more than the recommendation for hyperbaric oxygen therapy. The patients condition was improved following treatment with steroid injections. The patient experienced onset of hearing loss. Subsequently, the patient reported a sudden worsening in their hearing. Based on the medical literature, the onset is well outside the timeframe for recommended treatment after onset. Researchers compared hyperbaric oxygen therapy to steroids for salvage treatment of refractory sensorineural hearing loss, found no significant difference in audiometric outcomes between the groups using hyperbaric oxygen therapy or steroid injections. There is a lack of evidence that hyperbaric oxygen therapy would be more beneficial for this patients sensorineural hearing loss than existing alternatives such as steroids, particularly given the distant onset of hearing loss and the improvement in the patients audiometric outcomes after receiving steroid injections. In summary, the requested hyperbaric oxygen therapy 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 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 reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in otolaryngology and is 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: The patient has requested authorization and coverage for Xifaxan (rifaximin tablet 550 mg). Findings:  The physician reviewer found that the patient has a diagnosis of irritable bowel syndrome (IBS) with diarrhea. Pimental and colleagues note that among patients who had IBS without constipation, treatment with rifaximin (brand name Xifaxan) for two weeks provided significant relief of IBS symptoms, bloating, abdominal pain, and loose or watery stools. Lembo and colleagues note that in a phase 3 study of patients with relapsing symptoms of IBS with diarrhea, repeat rifaximin treatment was efficacious and well tolerated. The American College of Gastroenterology recommends the use of rifaximin for reduction in global IBS symptoms, as well as bloating in non-constipated IBS patients. In this clinical setting, current medical literature supports the use of the requested medication. Therefore, Xifaxan (rifaximin tablet 550 mg) is medically necessary for the treatment of this patient. 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 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 authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine (CPT 72148).The American College of Radiology (ACR) appropriateness criteria indicates that for patients with subacute or chronic low back pain with or without radiculopathy who are candidates for surgery or intervention, a non-contrast MRI is usually appropriate. Additionally, the American Society of Neuroradiology (ASNR) practice parameters for MRI of the adult spine states, MRI provides a precise representation of the anatomy and the degenerative conditions of the disc, spinal canal, discovertebral complex, and facet joints that will promote accurate diagnosis of degenerative disc disease and influence therapeutic decision making. It is well established as the modality of choice for evaluating degenerative disease of the spine.In this case, the patient has had multiple plain x-rays. The patient has also undergone conservative management. While conservative management may be useful, after an interval of three years since the last MRI, it is reasonable to obtain another MRI study. There are several entities that generally do not respond to conservative management, such as a bony stenosis. In this patient, since further interventions are being contemplated, a repeat MRI study is medically appropriate. Therefore, MRI of the lumbar spine (CPT 72148) is medically necessary for evaluation of the patients medical condition.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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for the requested anesthesia during colonoscopy (CPT 00812).According to Jensen and colleagues, class II obesity is categorized as BMI of 35 kg/m2 to 39.9 kg/m2. Patients with obesity, BMI over 30 kg/m2, are at a significantly higher risk for desaturation during endoscopy. In a study by Wani and colleagues, patients with BMI over 30 kg/m2 were found to be at higher risk for sedation-related complications during endoscopic procedures, with even higher risk for patients with BMI over 35 kg/m2. Per the most recent American Society for Gastrointestinal Endoscopy (ASGE) guideline for sedation and anesthesia in endoscopy, elevated BMI is an independent risk factor for hypoxemia during endoscopic procedures. In this case, the patient had a BMI of 36.5 kg/m2. Based on current medical literature, the patient is at increased risk for sedation-related complications. Thus, the requested anesthesia during colonoscopy (CPT 00812) is medically necessary for treatment of the patients medical condition.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 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 inpatient acute rehabilitation services at Childrens Specialized Hospital from 7/23/21 through 8/11/21.The submitted documentation supports the medical necessity of the services at issue. Mayer and colleagues conclude, An interdisciplinary team can best decide the appropriate level of rehabilitation care after an acute hospitalization. The authors also state, It requires interdisciplinary input and involvement of all stakeholders. The decision should be informed by outcomes data specific to the patients diagnosis, impairments, and psychosocial supports. In this case, the patient sustained severe trauma due to a motor vehicle accident, resulting in severe injuries to both lower limbs. The patient underwent extensive surgical care to the lower limbs and had significant restrictions on her lower limb weightbearing in order for these injuries to heal. Nevertheless, the patient had functional deficits and appropriate rehabilitation goals despite these restrictions. In particular, she needed to maximize her bed mobility, slide board transfers, popover transfers, and self-care without being able to stand. There had been a substantial change in the patients health and function in comparison to her baseline and multidisciplinary rehabilitation to address potential effects on her long-term health and function. The patient participated in intensive therapies and made gradual, but clinically meaningful, functional progress during the time period under review. There were intensive rehabilitation needs, need for close supervision/management/rehabilitation oversight, and need for 24-hour per day rehabilitation nursing availability during this time period, which supports the medical necessity of acute inpatient rehabilitation level services. Therefore, inpatient acute rehabilitation services at Childrens Specialized Hospital from 7/23/21 through 8/11/21 were medically necessary for treatment of 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 physical medicine and rehabilitation 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 reimbursement for radiofrequency ablation procedure (CPT 36475) on the left leg and radiofrequency ablation procedure (CPT 36475) on the right leg. The submitted documentation supports the medical necessity of the services at issue. In this case, the records documented that the patient was having significant symptoms attributable to the varicose veins. The records documented evidence of severe reflux in the veins that were treated, and that the treatments performed were limited to the veins with documented reflux. Given that the services at issue were appropriate for the documented symptoms, the services at issue were medically indicated. Therefore, radiofrequency ablation procedure (CPT 36475) on the left leg and radiofrequency ablation procedure (CPT 36475) on the right leg 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for combination therapy using Opdivo (nivolumab) and Yervoy (ipilimumab). The U.S. Food and Drug Administration (FDA) has not approved Opdivo and Yervoy for the treatment of patients with triple negative breast cancer and this regimen is not supported by major drug compendia or the medical literature. Currently, the regimen of Opdivo and Yervoy is the subject of ongoing clinical trials. The current NCCN guidelines and peer-reviewed medical literature support treatment of metaplastic breast cancers similarly to other invasive breast cancers. Current data support therapies such as a PARP inhibitor, pembrolizumab, or Sacituzumab. All told, combination therapy using Opdivo (nivolumab) and Yervoy (ipilimumab) was not and is not 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 that combination therapy using Opdivo (nivolumab) and Yervoy (ipilimumab) was not and 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 medication regimen at issue was not and 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 reviewer 1 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is 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.