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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Smart Pill Motility Testing System (CPT 91112).Findings:  The physician reviewer found that Treatment of constipation revolves around adequate water and fiber intake. Medical therapy involves use of fiber buking agents, osmotic laxatives and other agents for refractory constipation. Typically, constipation can be caused by slow transit or defecatory dysfunction caused by dyssnergic defecation. Dyssnergic defection can be evaluated using anorectal manometry testing. Colonic transit abnormalities can be evaluated by use of radiographic studies such as Sitz marker studies and SmartPill wireless motility capsule. In this case, the patient presents with chronic symptoms of abdominal pain, nausea, gas-bloat and constipation. There are no randomized controlled trials that have proven that the SmartPill capsule is safer and more effective and further improves health outcomes compared to conventional methods such as the Sitz marker study. Accordingly, the requested Smart Pill Motility Testing System (CPT 91112) is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in gastroenterology, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Findings: Two out of three physician reviewers found that the requested Smart Pill Motility Testing System (CPT 91112) is not likely to be more beneficial than any other available standard treatments for the patients 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 referral to a behavioral health therapist. Based on the medical records provided, there is a lack of information in the medical records to substantiate a diagnosis of a personality disorder. The records do not indicate that the patient has psychiatric symptoms as a target for his treatment aside from social anxiety. The patient has difficulty with social relationships, which would best be addressed through group therapy, although the patient has repeatedly declined these services. All told, the requested referral to a behavioral health therapist is not medically necessary for treatment of this patient.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 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 computed tomography (CT) scan of the brain. The records provided for review document that this patient presented to his provider with complaints of dizziness and ear discomfort. The patient has requested evaluation with a CT scan of the brain. However, there is no documentation of any focal neurological signs to support an indication for a CT scan of the brain. For patients with focal neurological signs, there are data supporting a limited role for evaluation with magnetic resonance imaging (MRI) due to increased sensitivity for assessing the posterior circulation of the brain. Since this patients records do not document any focal neurological signs or symptoms, additional imaging is not indicated. Therefore, the requested CT scan of the brain is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trikafta. Findings:  The physician reviewer found that records provided for review document that this patients cystic fibrosis genotype encodes a truncated W1282X cystic fibrosis transmembrane conductance regulator (CFTR) protein variant, subject to nonsense-mediated decay (NMD) of mRNA transcripts, resulting in insufficient protein production. The patients provider has recommended treatment with Trikafta, which is U.S. Food and Drug Administration (FDA) approved for the treatment of non-F508del cystic fibrosis genotypes. However, due to an absence of response in vitro, the cystic fibrosis alleles W1282X and 2183delAA>G are not eligible for CFTR modulator therapy. Although recent research suggested the functional rescue of W1282X CFTR in patient-derived nasal cultures, these cells were treated with NMD inhibition in addition to protein modulators, which does not establish that the in vitro response was attributed to the effect of protein modulators alone. Overall, there are insufficient evidence to support the use of Trikafta for the management of the W1282X and 2183delAA>G genotype cystic fibrosis. Therefore, the requested Trikafta is not medically necessary for treatment of this patient. 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 internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucynta 50 mg Extended Release tablets. Findings:  The physician reviewer found that guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and nonopioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. In this case, the patient has chronic low back pain due to lumbar spondylosis. The provider charted that the patient has been able to successfully manage her pain with a combination of long- and short-acting Nucynta. The patient reported increased back and neck pain and she requested an adjustment to a long-acting medication. The records document that the patient has been participating in a multimodal treatment plan including interventional therapy, most recently, with lumbar facet injections in November 2020. The provider reported that the patient has been able to perform the activities of daily living and function with her current medication regimen of Nucynta ER and immediate release. On 1/14/21, the provider noted that that patients CURES reports and urinalysis have been consistent with her therapeutic regimen. In addition, there is no indication that the patient has demonstrated aberrant behavior. Based on these findings, treatment with Nucynta is consistent with the CDC guidelines as part of a multimodal treatment plan including pain management procedures. All told, the requested Nucynta 50 mg Extended Release tablets are 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 anesthesiology with subspecialty certification in 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Vertiflex procedure. This patients medical condition is lumbar spinal stenosis. His provider has recommended the Vertiflex procedure since the patients pain did not substantially improve with medications, physical therapy, and epidural steroid injections. Lumbar stenosis may be treated with multiple modalities including traditional decompression, with or without fusion. Newer techniques, including the minimally invasive lumbar decompression and interspinous process devices, are also available for implementation. The Vertiflex procedure is a non-fusion device that is used in minimally invasive treatment of lumbar spinal stenosis. Moojen and colleagues discussed some important differences between Vertiflex and traditional, open decompression. Per the authors, the rates of reoperation in patients with the Vertiflex device were considerably higher than those in the decompression group. Open decompressive lumbar spine surgery is likely to be of greater benefit to this patient than the Vertiflex procedure, based on the available peer-reviewed medical literature and clinical trial outcomes. Accordingly, the requested Vertiflex procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Vertiflex procedure 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 reviewers 1, 2, and 3 are board certified in neurological 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 a Decision Dx-Melanoma assay.Findings: Three out of three physician reviewers found that the Decision Dx-Melanoma assay at issue was not likely to have been more beneficial than any other available standard treatments for the patients medical condition.NCCN Clinical Practice Guidelines do not currently recommend the Decision Dx test for cutaneous melanoma. There is no literature to support its use in the care of patients with thin melanomas to effect health outcomes. While there is literature to suggest that it may be beneficial for patients with melanomas to predict whether there is risk for metastasis based on phenotype, there is no current data to determine what to do with the information provided by the test. At this time, there are no formal standard procedures or precautions that would be changed in light of the data. The American Academy of Dermatology Guidelines of Care for primary cutaneous melanoma from January 2019 do not show any practical benefit in this testing with regard to clinical utility. There is not enough published data to support its routine use currently. Clinical trials are required to determine the utility of the results of the test to effect health outcomes. Most recently, JAMA Dermatology showed that the gene expression tests like Decision Dx for patients with AJCC stage one or two melanoma have poor performance in predicting outcomes. In this case, the treatment of the patient would not change based on the results of the Decision Dx-Melanoma assay. Under these circumstances, patients would still be required to have wide local excision and follow up skin surveillance. Therefore, the Decision Dx-Melanoma assay at issue was not likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any other available standard treatments for the patients medical condition. 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. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 Tymlos Pen Injector. Findings: Tymlos is a parathyroid hormone analogue that increases bone formation. Guidelines indicates that Tymlos is indicated in patients with severe osteoporosis and patients with multiple vertebral fractures. Per the Endocrine Society guidelines, severe osteoporosis is defined as a T score of -3.5. In this case, the patients DEXA scan showed worsening scores from -2.7 to -3.2, which does not support severe osteoporosis. In addition, there is no documentation of recent or previous vertebral fractures. Based on these findings, the patient does not meet the criteria for initiation of Tymlos therapy for the treatment of severe osteoporosis or for multiple vertebral fractures. Therefore, the requested Tymlos Pen Injector is not medically necessary for treatment of this patient. 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 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 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 Monovisc injection in the left knee. 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 a history of a lateral meniscal tear and osteoarthritis and is status post arthroscopic surgery. The patient has tried and failed other conservative treatments, including physical therapy, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, a Monovisc injection in 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 in both knees.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 options are limited. The patient has tried and failed other conservative treatments and desires to delay total knee arthroplasties. There is sufficient support for the requested services in this clinical setting. Therefore, Synvisc One injection in both knees are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the prescription medication Depo-Estradiol. The North American Menopause Society (NAMS) notes that hormone therapy (HT) remains the most effective treatment for vasomotor symptoms and the genitourinary syndrome of menopause and has been shown to prevent bone loss and fracture. The authors further note that treatment should be individualized to identify the most appropriate HT type, dose, formulation, route of administration, and duration of use. While Depo-Estradiol is typically not considered a first line treatment, in this case, the patient has reported significant skin irritation with transdermal therapy and was unable to tolerate oral therapy due to gastrointestinal side effects. Given that the patient reports good symptom control without side effects using Depo-Estradiol, the requested medication is medically indicated. Therefore, prescription medication Depo-Estradiol 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a regimen of three (3) Rituxan 1,000 mg infusions. Researchers note that rituximab is considered a first line treatment for moderate and severe pemphigus vulgaris. The authors note that the usual dosing regimen is two infusions of 1,000 mg, spaced two weeks apart, and a third dose as early as six months after the initial infusions. In this case, the patient has a diagnosis of pemphigus vulgaris. Given current medical literature, the requested medication regimen is medically indicated in this clinical setting. Therefore, a regimen of three (3) Rituxan 1,000 mg infusions is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.