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

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of her medical condition. Findings: Three physician reviewers found that in this clinical setting, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phosholipase A2 (Lp-PLA2), lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits. Therefore, advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: All three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty 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: An enrollee has requested residential treatment services for treatment of her medical condition.   Findings: The physician reviewer found that the records indicate that this patient was experiencing mild post-acute withdrawal symptoms (PAWS). The patient was not a danger to herself or others. The patient was medically stable and psychiatrically she did not require residential treatment. There was no evidence of emotional, behavioral, or cognitive barriers to treatment at a lower level of care. The patient did not require 24-hour supervised care in a residential setting and could have continued her recovery at a lower level of care in conjunction with community support such as AA along with her sponsor. All told, residential treatment services were not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested the Prometheus Anser IFX test for evaluation of the enrollees Crohns disease.  Findings:  Two physician reviewers found that  medical studies support the use of therapeutic drug monitoring which is being used with increasing frequency to predict durability of response to therapies. Testing is also used to guide decision making in those patients not responding adequately to medication. Literature published over the past several years increasingly points to the benefits of therapeutic drug level monitoring as a means of preventing unnecessary exposure to medication and assisting providers to make timely decisions regarding switching medications within the same class or to another class. Several algorithms have been proposed to their use and have been widely adopted. At this point, these tests are used in centers that serve large populations of inflammatory bowel disease (IBD) patients primarily in an attempt to maximize and prolong the benefit of a very useful drug category. One groups 10 year experience identified loss of response to infliximab in line with other studies at 12% after year one and pointed to the likely relationship to development of antibodies to infliximab (ATI).. Empiric dose adjustment no longer seems reasonable in a time when data is available for guiding those decisions. This is especially true in the pediatric population where timely decision making regarding choice of drug is critical to preserving growth and decreasing the likelihood of surgery. Aside from the role for routine monitoring, several factors in this case made assessing the drug level important.  Waiting for clinical symptoms to develop in response to inappropriate or inadequate dosing in this clinical setting is not consistent with optimal management. Additionally, the provider was attempting to ascertain the role of combination therapy (methotrexate); much of the benefit of a second agent seems to come from decreasing anti-drug antibodies and given the elevated ALT while on methotrexate it would be appropriate to see whether adequate drug levels could be maintained without its use. For all these reasons, the Anser IFX test for evaluation of this patients medical condition was likely more efficacious than any available standard therapy.  Final Result:  Two reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested intravitreal Avastin eye injections for treatment of his medical condition.   Findings: Three physician reviewers found that the services at issue have been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is sufficient support for the services at issue in this clinical setting. According to the report on bevacizumab treatment for radiation retinopathy affecting the macula by Finger, Intravitreal bevacizumab can be used to treat radiation retinopathy. In most cases treatment was associated with decreased vascular leakage, stabilization, or improved vision. Thus, Avastin has been shown to be effective in restoring vision lost in patients who developed radiation maculopathy after radiation therapy. Given the support above, Avastin eye injections  were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: All three reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in ophthalmology 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 radiofrequency neurolysis for treatment of her medical condition.  Findings:  Two physician reviewers found that sacroiliac (SI) joint pain is a well-documented syndrome, which can generally involve infection, malignancy, and acute or repetitive trauma. Along with conservative measures like anti-inflammatories, heat, ice and some manipulation, SI joint injections have shown some merit in regards to fluoroscopic guidance with local and steroid with inter-articular placement of the medication. In the Muhlner review, radiofrequency neurotomy was reviewed noting limited evidence. There was variability not only with nerve patterns studied, but electrode positioning was different with many of the studies. Noting in the review by Hansen, controlled-double confirmative blocks with a long acting and short acting local anesthetic was found to be the gold standard for diagnosis of SI joint pain, showed a prevalence of about 25-30%. Radiofrequency neurotomy was found in some reviews to have long-term relief; however, a majority of articles reviewed were retrospective studies once again showing variable locations of denervation with use of strip lesions, monopolar and bipolar lesions of nerves from the medial branches from L4, L5, down to S1, S2, and S3. Overall, there is limited evidence for radiofrequency neurotomy. The Cohen study did show some intermediate improvement but the study was a very small double-blind study regarding SI joint radiofrequency ablation along the L4 and L5 primary dorsal rami and S1-3 lateral branches. The study group consisted of 28 patients and results were limited to two individuals who had relief up to one year after treatment. In light of medical reviews noted above and very small randomized-control study, the SI joint radiofrequency neurolysis was not likely to be more efficacious in treatment of this patients SIJ pain, at this time.  Final Result: Two reviewers determined that the procedure at issue was 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:   All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency services provided an emergent or urgent basis for treatment of her medical condition.   Findings: The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not believe she was experiencing an emergency medical condition. The patients stated symptoms are not noted in the records submitted. There is a lack of clinical documentation demonstrating that the patient presented with acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. There is no documentation submitted showing the patients pain rating severity. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care.  Moreover, it has not been established that criteria for urgently needed services were met. The patient had a known medical condition. There is a lack of documentation supporting that the services at issue were necessary to prevent serious deterioration of the health of the patient for which treatment cannot be delayed until the she returned to the Plans service area. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed urgent medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for urgently needed services. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology 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:   An enrollee has requested a single-site abdominal robotic-assisted hysterectomy, non-vaginal for treatment of her medical condition.  Findings:  The physician reviewer found that this is a patient who has requested a hysterectomy as definitive treatment for her medical condition and due to her history, she has requested a procedure that involves no vaginal instrumentation. However, the medical records include a prior laparoscopy that does not support a diagnosis of endometriosis, which may be an indication for the requested procedure. Further, a robotic laparoscopic approach, just like that of a standard laparoscopic hysterectomy, must use vaginal instrumentation to manipulate the uterus and move it from side-to-side for access, which is particularly necessary with a single-site approach. This helps to protect the bladder and uterus from injury during the dissection, and the device also delineates the connection of the vagina to the cervix, which cannot be easily identified otherwise. The patient indicates that the vaginal cuff would be closed via laparoscopic suturing if done robotically, but this can also be done with standard laparoscopic hysterectomy. In this case, there is a lack of medical or surgical advantage to a robotic procedure if this patient opts for a laparoscopic hysterectomy. All told, the medical records demonstrate that the requested single-site abdominal robotic-assisted hysterectomy, non-vaginal procedure is not medically necessary for treatment of this patients medical condition.  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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are esperts 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 a prosthetic implant and osteochondral knee allograft procedure for treatment of her medical condition.   Findings:  Two physician reviewers found that there is a lack of scientific evidence that the proposed treatment with the DeNovo NT and Biogide implants is likely to be more effective than other more standard treatments in this clinical setting. DeNovo NT is in early phase II trials with small case series and no published comparative trials. Yanke and colleagues noted that long-term outcome studies are not available. Early trials are ongoing and at this time, there is limited evidence of safety and efficacy and a paucity of evidence the DeNovo NT graft is more effective than standard approaches. Accordingly, the requested authorization and coverage for a prosthetic implant and osteochondral knee allograft procedure is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested procedures 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:  All three reviewers are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested physical therapy for treatment of her medical condition.  Findings:  The physician reviewer found that the Official Disability Guidelines and American College of Occupational and Environmental Medicine (ACOEM) practice guidelines support the use of physical therapy to instruct patients with low back pain in strengthening exercises. Manual therapy is also supported as beneficial. The guidelines specifically endorse the use of outpatient physical therapy as well as exercise instruction so that patients can independently manage their low back pain. Consistent with these findings, the requested physical therapy is medically necessary for treatment of this patients low back pain.  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 physical medicine and rehabilitation, pain medicine, and occupational 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an epidural steroid injection for treatment of her medical condition.  Findings:  The physician reviewer found that the records provided for review do not support the requested epidural steroid injection as medically necessary for treatment of this patients medical condition. The patient has been treated with physical therapy. However, there is no documentation of a home exercise program or how long the patient was treated with physical therapy. The literature indicates that a home exercise program after physical therapy independent of an epidural can give a patient lasting results. In addition, the patient does not have any recent physical exam findings and imaging supporting a diagnosis of cervical radiculopathy at the C3-4 level, instead the physical exam and imaging supports a diagnosis at the C6-7 level. Therefore, the request for an epidural steroid injection is not medically necessary for treatment of this patients medical condition.   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 anesthesiology and pain management 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.