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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for an arrhythmia and cardiomyopathy genetic panel. The enrollee was diagnosed with cardiomyopathy at age 15. He experienced cardiac arrest at age 16 and is status post implanted cardiac defibrillator, with moderate mitral valve prolapse. The enrollee has experienced multiple implantable cardioverter-defibrillator shocks, frequent premature ventricular contractions and atrial arrhythmia. The treating provider recommended the arrhythmia and cardiomyopathy genetic panel testing to assess for hereditary cardiomyopathy and/or possible malignant mitral prolapse syndrome. Genetic testing for cardiomyopathy is not considered the standard of care for the management of enrollees with known or suspected cardiomyopathies. There is no evidence of malignant mitral valve prolapse syndrome, which would warrant testing. Genetic testing has not been proven in clinical research trials to provide information which affects outcomes in enrollees with known or suspected cardiomyopathies, and is not recommended by professional societies in this clinical context.Final Result: Two of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in cardiovascular disease 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for skilled nursing facility level of care. The enrollee underwent a right total knee arthroplasty and entered a skilled nursing facility for rehabilitation. The enrollee required physical therapy and occupational therapy services to increase independence with gait, facilitate independence with all functional mobility, improve dynamic balance, increase functional activity tolerance and increase lower-extremity strength. This would enable the enrollee to return to her private residence with a reduced risk for falls and an ability to perform transfers with increased safety. Physical therapy notes show the enrollees bed mobility, transfer ability, and ability to climb stairs improved. Occupational therapy notes demonstrated a similar level of improvement.  The enrollee was also able to ambulate with a rolling walker with only stand-by assistance. Literature reports skilled nursing interventions greatly enhance an individuals functional ability, balance, transfer ability and performance of activities of daily living. Literature demonstrated that those who did not receive such interventions showed deterioration in these abilities.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Durolane injection of the right knee. The enrollee has osteoarthritis of the right knee. Her physician reports she has tried and failed various treatments, including Supartz, Kenalog, and naproxen sodium. She has pain going up and down stairs. She is requesting Durolane (hyaluronic acid) injections to the right knee. The enrollees physician states the goal of treatment with Durolane is to decrease pain, maintain or improve joint movement, and limit the loss of joint function. The literature summarizing the hyaluronic acid injections, such as Durolane, is well documented in the American Academy of Orthopaedic Surgery guidelines. In general, the use of hyaluronic acid is not supported in the literature due to the fact that most studies show it does not show superiority over other treatments, including placebo.  The studies in which some people reached a statistical improvement usually did not meet minimally clinically important difference criteria. The enrollees physician indicates that, since steroids injections did not work, the enrollee is a candidate for Synvisc-One.  However, this conclusion has not been demonstrated in literature. While it is discussed as a treatment for people who have failed steroid treatment, it is not evidence that hyaluronic acid injections would work.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in rheumatology 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 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 Supartz injections (CPT 99213, 20610, and J7321) to the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. This patient presents with a history of chronic right knee pain exacerbated by kneeling and squatting. The provider has documented the presence of osteoarthritis of the medial and lateral compartments and a degenerative tear of the medial meniscus on the magnetic resonance imaging (MRI) scan. Treatment has included non-steroidal anti-inflammatory drugs (NSAIDs) such as Relafen and Voltaren, a knee support, and a corticosteroid injection without significant benefit. In light of the degenerative changes, the provider is hesitant to perform arthroscopy. The provider instead recommended a trial of viscosupplementation prior to considering surgical intervention. Given the support in the medical literature, the requested Supartz injections (CPT 99213, 20610, and J7321) to the right knee are 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 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 Hizentra 13 gram subcutaneous infusion (CPT code J1559) administered at an ambulatory infusion center every week.The submitted documentation supports that the requested medication is medically necessary. Researchers note that human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. In this case, the patients laboratory data support the diagnosis of specific antibody deficiency. In 2017, the patients pneumococcal antibody titers were only positive for 4 out of 14 antibody titers and did not improve upon vaccination with pneumovax and rechecking the values four weeks after vaccination. This testing confirms the patients diagnosis of specific antibody deficiency, in the setting of recurrent sinopulmonary infections. Under these circumstances, immunoglobulin replacement therapy is an appropriate and medically necessary treatment for the patient. Accordingly, Hizentra 13 gram subcutaneous infusion (CPT code J1559) administered at an ambulatory infusion center every week is medically necessary for the patients medical condition.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 both internal medicine and allergy and immunology, 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

The enrollee is requesting authorization and coverage for Synvisc-One injections in both knees. The enrollee has bilateral knee osteoarthritis. The enrollee reported she was able to ambulate better and perform more activities after the injections; however, due to her back and knee problems, her activity level has declined. The enrollee has not engaged in physical therapy for her lower extremities. She does not perform any exercises on her own. The enrollees orthopedic surgery provider has recommended physical therapy for strengthening of the lower extremities, Synvisc-One injection for bilateral knees, and tramadol for pain. Medical records show the enrollee has bilateral knee osteoarthritis and has received previous viscosupplementation (Synvisc-One injections), with improvement in symptoms and activity levels. However, the degree and duration of improvement associated with the previous course of injections were not reported in the medical records. In addition, the dates of the prior injections were not supported by the medical records. Typically, repeat injections are given every six months. The medical records do not supply sufficient details regarding the prior injections.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 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 the medication Norco.Centers for Disease Control and Prevention (CDC) guidelines for the prescribing of opioids for chronic pain state that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. The guidelines state that clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. Federation of State Medical Boards guidelines for the chronic use of opioid analgesics state that continuation, modification or termination of opioid therapy for pain is contingent upon a clinicians evaluation of evidence of the patients progress toward treatment objectives and the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.In this case, the submitted documentation includes Addiction Medicine records that indicate that the patient has a diagnosis of severe opioid use disorder on maintenance therapy and that he has recently acknowledged using illicit opioids. Guidelines recommend discontinuing opioid therapy in patients displaying aberrant substance use behaviors. The risks of combining opioid therapy with a patient who is concurrently demonstrating self-prescribing behaviors outweigh any potential benefit of chronic opioid therapy. Under these circumstances, the medication Norco is not medically necessary to treat 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 anesthesiology, with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet rich plasma (PRP) injections for bilateral knees. There is limited reliable clinical evidence to guide the use of PRP. Although no major or permanent complications have been reported in short-term clinical trials, there is a paucity of prospective randomized controlled clinical trials demonstrating improved patient health outcomes with PRP over standard therapies. Researchers found that the effects of PRP on knee osteoarthritis are mixed and the research is limited. Researchers concluded that PRP should not be preferred to hyaluronic acid. Authors concluded that leukocyte-poor PRP resulted in improved functional outcomes as compared to leukocyte-rich PRP, hyaluronic acid, and placebo injections. Given these findings, the requested PRP injections for the bilateral knees are 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 the requested PRP injections for the bilateral knees are 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery 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 4Kscore test (CPT code 81539) and the ConfirmMDx gene test (CPT code 81551).  This patient with an elevated PSA underwent 4Kscore testing and ConfirmMDx testing to help assess his risk for prostate cancer. The National Comprehensive Cancer Network (NCCN) guidelines do not consider 4Kscore testing or ConfirmMDx the standard of care for evaluation of patients with elevated PSA levels. While 4Kscore or ConfirmMDx may eventually have a role in this clinical setting, there are insufficient data on long-term patient health outcomes to support routine use in screening patients for prostate cancer. For these reasons, the 4Kscore test (CPT code 81539) and the ConfirmMDx gene test (CPT code 81551) were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the 4Kscore test (CPT code 81539) and the ConfirmMDx gene test (CPT code 81551) were 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for pantoprazole sodium DR. The enrollee has a history of gastroesophageal reflux disease, coronary artery disease, and a myocardial infarction. He was admitted with a second myocardial infarction. He underwent a cardiac catheterization with stent placement. During admission, it was noted that he had been taking his Pravastatin and Plavix only every other day due to dark stools. While in enrollee, his medications were changed to Crestor, Plavix, and aspirin, and pantoprazole was added to his medication regimen. This enrollee was prescribed pantoprazole; however, there is no contraindication for the use of an alternative proton pump inhibitor. Records do not indicate the enrollee has tried or failed an alternative proton pump inhibitor. The use of pantoprazole is not superior to other proton pump inhibitors in this drug class. Though this medication is Food and Drug Administration-approved for the treatment of gastroesophageal reflux disease and/or gastrointestinal bleeding, it is not necessary for this enrollee to use this medication instead of other available medications. Literature shows there are no significant differences among equivalent doses of proton pump inhibitors for the treatment of non-erosive gastroesophageal reflux disease. Therefore, the choice of agent is an unlikely cause of refractory gastroesophageal reflux disease. This enrollees medical condition can be equally treated with other proton pump inhibitors.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for neck surgery. The enrollee has neck pain. At an office visit, the orthopedic surgeon reported the enrollee had radiation of his neck pain to his arms and numbness of his right hand. The enrollee walks with his head thrust forward and can bring his head to neutral, but with significant pain. The surgeon reports an x-ray of the cervical spine showed significant degeneration. Magnetic resonance imaging of the neck revealed stenosis and marked kyphosis, with pressure on the anterior cord causing displacement. The outcomes of anterior cervical discectomy and fusion are generally positive.  A systematic review of studies found good outcomes. Evidence in the literature suggests superior surgical outcomes in anterior cervical discectomy and fusion procedures with anterior plate fixation.  A literature review also found that anterior cervical discectomy and fusion was the dominant strategy for individuals with radiculopathy; compared to non-operative options, such as epidural injections.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for occupational therapy services. The enrollee received occupational therapy on for sensory processing difficulty, motor delay, lack of coordination, difficulty with activities of daily living, and feeding difficulties. Records show the enrollee demonstrated decreased strength, decreased endurance, decreased self-care skills, and decreased safety. Records show he was struggling with a variety of food textures, clothing textures, fine motor skills, writing, and pedaling a tricycle. Literature shows atypical behavior can negatively influence a child's enjoyment and participation in everyday activities. Poor participation in everyday activities negatively affects developmental skills. Allen and colleagues indicate occupational therapy is the standard of care for children with developmental delays and/or a sensory processing disorder.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.