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 DecisionDx-Melanoma gene test. Findings:  The physician reviewer found that he pathology report did not document any high risk features such as ulceration. The recommendation for treatment of a stage 1A melanoma is to perform a wide local excision. The DecisionDx Melanoma is used to estimate risk of recurrence and was reported as Class 1A for this patient. Based on the test, the patient has the lowest risk of recurrence at five years. However, per Swetter and colleagues, routine molecular testing including gene expression profiling (GEP) with DecisionDx-Melanoma for prognostication is discouraged until better use criteria are defined. Per the NCCN, the currently available prognostic molecular techniques should not replace pathologic staging procedures. Given that this patients melanoma is superficial without high-risk features, additional testing with DecisionDx-Melanoma was not likely to be more beneficial than standard risk profiling. Given these findings, the DecisionDx-Melanoma gene test was 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 DecisionDx-Melanoma gene test was 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 evaluation 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 dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for home skilled nursing services.Myasthenia gravis is a disorder of neuromuscular transmission that results in fluctuating muscular weakness and fatigue. In adults, the disease is autoimmune in nature, due to antibodies against the acetylcholine receptors in the neuromuscular junction. The congenital myasthenic syndromes, in contrast, are genetic disorders (not autoimmune disorders) that cause the formation of dysfunctional proteins in the neuromuscular junction. Congenital myasthenia is very rare and causes ocular, bulbar and limb muscle weakness of varying severity.In this case, the patient has a congenital myasthenia that has affected his speech, swallowing and respiratory function. He has mild weakness in the proximal upper limbs and in the lower limbs. There is more significant weakness in the distal upper limbs. He is largely independent with his self-care except for activities that require more fine motor function such as tying shoelaces and managing buttons. He is independent with transfers and can walk up to half a mile typically, without difficulty. He does have and use ankle foot orthoses. He requires tube feeds, cough assistance and mechanical ventilation at night. There is a history of autism and some cognitive impairment due to perinatal anoxia with some impaired judgment and safety awareness, but he is in college and able to read and play video games.The records, overall, do not support the medical necessity of skilled nursing services daily. The patient requires assistance for some tasks, which can be provided by a caregiver or other unskilled aide who is trained. He requires supervision due to safety. Medical oversight can be provided by his physician and intermittent home nursing visits. Therefore, home skilled nursing services were not, and are not, medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patients condition. Therefore, the Health Plans denial should be upheld.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 authorization and coverage for Supartz injection, with aspiration. Findings: 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 indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Supartz injection, with aspiration 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: The patient has requested authorization and coverage for left heart cardiac catheterization and heart artery ventricle angiography. The records provided for review document that this patient has several risk factors for cardiovascular disease. She has typical and atypical chest pain symptoms and nuclear stress findings reported as positive for anterior ischemia. She was started on medical therapy without substantial improvement in her symptoms. She has described exertional and rest symptoms as well as medication side effects limiting treatment options. This patient meets the American Heart Association (AHA) and American College of Cardiology Foundation (ACCF) appropriate use criteria for cardiac catheterization and coronary angiography as an intermediate risk patient with persistent and life-limiting symptoms despite medical therapy. For these reasons, the requested left heart cardiac catheterization and heart artery ventricle angiography is medically necessary for 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 internal medicine with subspecialty certification in cardiovascular 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 patient has requested authorization and coverage for cervical disc replacement surgery. Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical disc replacement surgery.A review of the recent medical literature with respect to cervical replacement in hybrid surgery for multi-level degenerative disc disease, demonstrates favorable clinical outcomes at short- as well as long-term. Cervical disc arthroplasty has been demonstrated to be a safe and effective treatment modality for single-level cervical radiculopathy or myelopathy, and also for two contiguous levels and hybrid constructs. The advantages of cervical disc arthroplasty over an anterior cervical discectomy and fusion include motion preservation, decreased revision rate, improved patient comfort and satisfaction with the procedure, and lesser degree of adjacent level disease. Data from one clinical study reported superior results when compared to anterior cervical discectomy and fusion up to seven years of post-operative follow-up. This patient underwent two-level anterior cervical discectomy and fusion. He has adjacent segment disease. Surgery is indicated since the patient has failed conservative treatment. The better procedure is a motion preserving hybrid total disc replacement as recommended by the patients provider. For these reasons, the requested cervical disc replacement surgery is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 acceptance into the liver transplant program for a liver transplant. The patients clinical status, with worsening decompensated cirrhosis complicated by decompensated cirrhosis including renal dysfunction, meets the American Association for the Study of Liver Disease (AASLD) guidelines for evaluation for liver transplantation (Martin, et al.). These guidelines specify that alcohol abuse is a contraindication to transplant. However, in this case, the patient has stopped alcohol use and is undergoing therapy as documented by more than one provider. Additionally, the patients original liver disease was not alcohol-related, and there is no documented longstanding history of alcohol abuse. The six-month requirement for abstinence has not been shown to affect survival or other outcomes (Marroni, et al.). Further, the American College of Gastroenterology (ACG) guidelines for alcoholic liver disease do not endorse the requirement for six months of alcohol abstinence to be considered for transplant (Singal, et al.). Liver transplant is a recommended intervention for primary biliary cholangitis according to AASLD guidelines (Lindor, et al.). For these reasons, the requested acceptance into the liver transplant program for a liver transplant is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for a referral to a urologist. Arnold and colleagues note that recurrent urinary tract infections (UTIs) are common in women, including healthy women with normal genitourinary anatomy, and that episodes of recurrent UTI are typically characterized by dysuria and urinary frequency or hesitancy. The authors further note that findings from a patients history or physical examination that suggest a complicated infection or another disease process warrant additional evaluation. In this case, the patient has recurrent lower urinary tract symptoms and flank pain. She has been seen multiple times by her provider without relief and her symptoms are not explained by laboratory results. Given that her persistent symptoms require further evaluation, the requested service is medically indicated. Therefore, a referral to a urologist is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Zulresso. Zulresso is U.S. Food and Drug Administration (FDA) approved for the treatment of post-partum depression. The inclusion criteria used in the randomized controlled trial data that was submitted included patients ages 18-45 with moderate to severe depression and less than six months post-partum. As a rapidly acting medication, Zulresso is administered via intravenous infusion over 60 hours in a supervised inpatient setting. The FDA has approved Zulresso only for use in REMS qualified programs with the ability to monitor the patient over 60 hours for adverse effects. The data submitted to FDA indicates that it is effective in improving depressive symptomology and is safe to use in breastfeeding mothers. In this case, the patient gave birth on 8/14/20 via cesarean section and she is less than six months post-partum. Per the medical documentation, the patient has a diagnosis of moderate major depressive disorder and she is younger than 45-years-old. The patient was evaluated and found to have a personal health questionnaire 9 (PHQ-9) score and symptom history consistent with moderate to severe depression. The patient has been treated with psychotherapy and a selective serotonin reuptake inhibitor with persistence of symptoms. The medical documentation suggests that the patient continues to have functional disabilities to care for herself and her child, placing their wellbeing at risk. Despite six weeks of intensive psychiatric treatment, the patients PHQ-9 supports moderate to severe depression. The patient has experienced some improvement with the structure of IOP and PHP. For these reasons, the medication Zulresso services is medically necessary for 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 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: The patient has requested authorization and coverage for (1) hydrocodone 10 mg, four times a day, or (2) hydrocodone 10 mg, three times a day. Findings:  The physician reviewer found that when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient presented with chronic pain with diffuse symptomology, Ehlers-Danlos syndrome, and interstitial cystitis. The records reflect that she is being treated with a buprenorphine patch, and that her providers, including pain management providers, have not recommended an escalation in treatment to hydrocodone. Given that this patient is being treated in a manner consistent with current medical literature, the requested medication is not medically indicated. Therefore, (1) hydrocodone 10 mg, four times a day, or (2) hydrocodone 10 mg, three times a day is not medically necessary for the treatment of this patient. This medical necessity decision should not be interpreted as a recommendation to stop opioids abruptly and the eligible patient is advised to speak with their treating physician. The treating physician and the eligible patient should decide upon an opioid reduction program. It is beyond the scope of the IMR process to specify a specific tapering schedule. The treating physician and the eligible patient are advised to consult the Centers for Disease Control and Prevention (CDC) Guide to Tapering Opioids that provides further opioid weaning guidance.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 sub-specialty 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 reimbursement and prospective authorization and coverage for ultrasound/phonophoresis twice per week. Findings:  The physician reviewer found that meta-analysis of randomized clinical trials of different treatments for androgynous temporomandibular disorder, Al-Moraissi and colleagues concluded that the most effective treatments for short-term and intermediate-term improvement were arthroscopy procedures, followed by platelet-rich plasma (PRP) and hyaluronic acid injections, and non-invasive therapies including physical therapy. The authors did not mention phonophoresis as a recognized treatment option with strong medical evidence. In reviewing the efficacy of phonophoresis in patients with temporomandibular disorders, Ramakrishnan and Aswath noted that while both phonophoresis and ultrasound therapy were effective in treating temporomandibular joint disorders, improvement with phonophoresis over traditional ultrasound did not demonstrate statistically significant evidence of superiority. In this case, the patient reports a two year history of chronic facial pain and temporomandibular joint pain. While she reports improvement with ultrasound treatments along with phonophoresis, current medical literature does not support the use of phonophoresis as standard of care for temporomandibular joint disorders. Therefore, ultrasound/phonophoresis twice per week were not and are not likely be more beneficial than any other available standard service for the patients medical condition.Findings:  Two of the three physician reviewers found the requested ultrasound/phonophoresis twice per week were not and 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 services at issue were not and 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 anesthesiology with sub-specialty certification in pain medicine 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Talicia 250-12.5-10 mg capsules. Chey and colleagues note that first-line treatment of Helicobacter pylori includes bismuth quadruple therapy or concomitant therapy consisting of a proton pump inhibitor, clarithromycin, amoxicillin, and metronidazole. The authors further note that if a patient fails a first-line treatment containing clarithromycin, bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options, while if a patient fails a first-line bismuth quadruple therapy, clarithromycin or levofloxacin-containing salvage regimens are the preferred treatment options. In this case, the patient has failed first-line treatments, and testing has found a resistance to clarithromycin. Given that guidelines recommend a rifabutin-based salvage regimen as the next treatment step in this clinical setting, the requested medication is medically indicated. Therefore, Talicia 250-12.5-10 mg capsules are 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.