Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for future oocyte cryopreservation services. Treatment of medulloblastoma requires administration of gonadotoxic chemotherapy, which often leads to infertility. This patient is planned for a chemotherapy regimen with alkylating agents. As noted in the medical literature, cryopreservation of oocytes is a proven technique to aide in fertility preservation and is medically necessary for young women about to undergo gonadotoxic chemotherapy. With appropriate pretreatment planning and intervention, biologic parenthood is possible for this patient, who may lose reproductive function due to gonadotoxic treatment. Given these findings, the requested future oocyte cryopreservation services are medically necessary for treatment of this patients medical condition. 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 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 authorization and coverage for Euflexxa intra-articular injections for both knees. In the peer-reviewed medical literature, researchers reported on a meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. Intraarticular hyaluronic acid can provide improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has been demonstrated to be safe and effective. This patient has been treated with multiple conservative treatments, including Tylenol and meloxicam, for osteoarthritis in the past without substantial relief. Moreover, this patient has experienced relief with prior viscosupplementation injections. All told, the requested Euflexxa intra-articular injections for both knees are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is 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 authorization and coverage for a wearable cardioverter defibrillator.Findings: Two of the three physician reviewers found that a wearable cardioverter defibrillator is indicated under these circumstances. The patient had a recent myocardial infarction complicated by transient shock and now has a significantly reduced ejection fraction. The patient does not have an initial indication for an implantable defibrillator since they are less than 40 days since acute myocardial infarction and less than 3 months since PCI. A wearable cardioverter defibrillator can provide temporary protection from early sudden death due to arrhythmia in this patient population during this interim period. Although no randomized controlled prospective trials have been completed yet, this short-term indication for wearable defibrillator therapy has support. This support can be seen in large published case series literature, in a published longer term prospective registry, along with expert opinion and a AHA Scientific Advisory. Therefore, under these circumstances, a wearable cardioverter defibrillator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested device is 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:  One reviewer is board certified in internal medicine, with subspecialty certificates in cardiovascular disease and interventional cardiology, and is actively practicing. One Reviewer is board certified in internal medicine, with a subspecialty certificate in cardiovascular disease, and is actively practicing. One Reviewer is board certified in internal medicine, with a subspecialty certificate in cardiovascular disease, and is 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 authorization and coverage for Xeljanz XR 11 mg. Findings:  The physician reviewer found that this patient has been diagnosed with rheumatoid arthritis, but also has sicca syndrome and Raynauds disease. It is not clear that the patient does not actually have undifferentiated or mixed connective tissue disease, for which Xeljanz is not U.S. Food and Drug Administration (FDA) approved. The patient may not be able to tolerate nonsteroidal anti-inflammatory drugs or methotrexate, but the records do not document why the patient cannot be treated with multiple other non-biologic disease-modifying antirheumatic drugs or anti-tumor necrosis factor drugs, including Plaquenil, Arava, Imuran, sulfasalazine, CellCept, Enbrel or Humira. Disease-modifying antirheumatic drugs are considered first-line agents for the treatment of rheumatoid arthritis. After the failure of disease-modifying antirheumatic drugs, anti-tumor necrosis factor drugs are preferred prior to Xeljanz. The requested therapy with Xeljanz is not superior to the formulary plan preferred drugs in terms of efficacy or safety. Therefore, Xeljanz XR 11 mg is not medically necessary for the 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 sub-specialty certification 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking. Findings:  Two of three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Collagen cross-linking has been approved by the U.S. Food and Drug Administration for halting the progression of keratoconus. A key question that determines whether a patient should be treated is whether the keratoconus is still progressing. This can be established by a history of progressive blurriness and/or by serial testing. In this case, the patient has reported progressive blurriness in the right eye. More importantly, the patients young age and keratometry is consistent with a high risk of progression. Therefore, corneal collagen cross-linking was likely to have been of greater benefit than other treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  Two of the three physician reviewers found that the submitted documentation supports a portion of the services at issue. The American College of Obstetricians and Gynecologists recommends that screening for spinal muscular atrophy and cystic fibrosis should be offered to all women who are considering pregnancy or are currently pregnant. However, screening for Fragile X syndrome is not recommended for all pregnant women. Screening for Fragile X syndrome is not common practice due, in part, to the difficulty in predicting phenotype in offspring of low-risk women (women with a negative personal and family history) with a premutation. Therefore, spinal muscular atrophy carrier screening and cystic fibrosis screening were likely to have been of greater benefit than other methods of evaluating this patient. However, the superior efficacy of Fragile X screening has not been established. Final Result: The reviewers determined that a portion of the services 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 partially overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the MiniMed 670G insulin delivery system with continuous glucose monitoring. Findings:  Two of the three physician reviewers found that a continuous glucose monitoring system is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed, thereby maintaining tight glycemic control and preventing hyperglycemia and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals and show early morning spikes in blood sugar.  Studies have shown that use of a continuous glucose monitoring system can help optimize glycemic control and can lead to even greater improvement when used in conjunction with insulin pump therapy. The FDA recently approved the MiniMed 670G device, which is a hybrid closed-loop insulin delivery system for use in patients who are at least 14 years of age with type 1 diabetes. The system uses an algorithm to automatically adjust basal insulin doses based on readings from a continuous glucose monitor. This patient has suboptimal glycemic control with her current insulin pump with a high degree of variability and will likely benefit from the requested device. In sum, the requested MiniMed 670G insulin delivery system with hybrid closed loop technology is likely to be superior over other treatment options.Final Result: Two of the three reviewers determined that the requested device is 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: Physician reviewers 1, 2 and 3 are board certified in endocrinology and metabolism 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the whole exome sequencing (WES) genetic testing. As noted in the medical literature, WES is a newly available technology whereby the portion of the genome consisting of coding sequences is analyzed for variants that may explain a patients phenotype. Clinical indications for WES are a suspected genetic disorder based on signs and symptoms, with no known single gene condition fitting the phenotype. The utility of WES for gene discovery to identify the genetic cause of well-characterized specific phenotypes has been demonstrated in the current medical literature. The utility of WES in the clinical arena has been demonstrated to assist in diagnosis in approximately 25% of patients referred for testing. The majority of these patients had a neurological phenotype (intellectual disability), which is consistent with this patients presentation. Given these data, the WES genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in pediatrics and genetics and is actively practicing. One Reviewer is board certified in pediatrics and genetics and is actively practicing.  One Reviewer is board certified in pediatrics and genetics and is 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 authorization and coverage for Synvisc One injections for both knees. The submitted documentation supports the medical necessity of the requested services. Campbell and colleagues performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Per the authors, the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function. The authors noted that viscosupplementation has a good safety profile. The medical evidence supports the requested services in this clinical setting. Therefore, Synvisc One injections for both knees is 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Euflexxa injections. There is adequate data in the medical literature to support an indication for hyaluronic acid injections to diminish osteoarthritic knee pain. However, in this case, the documentation does not support a diagnosis of knee osteoarthrosis. The records attribute the patients knee pain to chondromalacia patella. Currently, there is a paucity of studies supporting a clinical indication of hyaluronic acid injection for anterior knee pain attributed to chondromalacia patella. Studies of hyaluronic acid injection for pain attributed to osteoarthrosis in the primary femoral-tibial articulation have reported mixed results. Currently, hyaluronic acid injections are considered second-line treatment for osteoarthrosis after independent exercise, weight loss and simple medications such as nonsteroidal anti-inflammatory medications and/or acetaminophen. In this case, there is no documentation of knee osteoarthrosis or that the patient has exhausted standard first-line treatments for nonspecific knee pain. For these reasons, the requested Euflexxa injections are not medically necessary for treatment of this patients knee pain. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensive outpatient program (IOP) services. The submitted documentation fails to demonstrate the medical necessity of the requested services. Despite a relapse while socializing with friends, the patient successfully completed chemical dependency treatment services and was prescribed an anti-craving medication, naltrexone. Upon presentation, the patient had a reassuring mental status examination with no craving, intoxication, physical ailments, safety issues or home environment concerns.  There was no input from treating providers articulating the factors and barriers precluding effective treatment in a less restrictive setting while it was unclear if the patient had previously pursued standard therapies, such as exposure response prevention or cognitive behavioral therapy, both of which are commonly provided in an office-based setting. Further, previous clinical documentation indicated that the patient did not have a therapist and had not been attending Alcoholics Anonymous, which suggests that the patient was not fully engaged in active treatment at the time. Thus, the records do not demonstrate that comprehensive care, including psychiatric services, evidence-based psychotherapy, chemical dependency counseling and community-based/sponsor-supported programming, delivered in accordance with a multidisciplinary treatment plan in the outpatient setting would be unsafe or inadequate. Therefore, the requested IOP services are not medically necessary for the 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the doppler-guided transanal hemorrhoidal dearterialization. The Health Plan has denied this request as investigational for treatment of the enrollees condition. Findings: A multicenter randomized trial of 393 patients with grade II or III internal hemorrhoids comparing hemorrhoidal artery ligation and stapled hemorrhoidectomy found that hemorrhoidal artery ligation resulted in less postoperative pain and a shorter sick leave but was more expensive, took longer to perform, left more residual grade III disease, and required more reoperations. Otherwise, hemorrhoidal artery ligation and stapled hemorrhoidectomy had comparable complication (24 versus 26 percent) and patient satisfaction rates (>90 percent in both groups). When compared to other non-excisional procedures for hemorrhoids, such as stapled hemorrhoidopexy (PPH), dearterialization may have the added advantage of reducing the incidence of serious complications. However, despite these advantages, long-term results may be associated with higher recurrence rates compared to conventional hemorrhoidectomy. Final Result: Two of the three 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/QualificationsAll three reviewers are board certified in gastroenterology 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.