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

The enrollee requested authorization and coverage, and reimbursement, for percutaneous tibial nerve stimulation. The enrollee has urinary urgency, frequency, and nocturia. He has decreased consumption of caffeine, spicy foods, citrus, and alcohol. He has been receiving percutaneous tibial nerve stimulation to help with his bladder control. His physician reported 100 percent improvement in overactive bladder symptoms after completing percutaneous tibial nerve stimulation for 12 weeks. There is evidence in the peer-reviewed literature from randomized trials supporting the effectiveness and impact of posterior tibial nerve stimulation in those with urinary urgency and frequency. However, most trials have a small number of participants with a short term follow-up. Only one open label trial has a 36-month follow-up. Professional society guidelines for overactive bladder report clinicians should offer behavioral therapies, such as bladder training, bladder control strategies, pelvic floor muscle training, and fluid management as first line therapy to all individuals with overactive bladder. The guidelines rate percutaneous tibial nerve stimulation as a recommended third line therapy. This enrollee is an acceptable candidate for percutaneous tibial nerve stimulation. Final Result: Two of the three reviewers determined that the requested services were not likely to have been, and are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in urology 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: The patient has requested authorization and coverage for onabotulinumtoxinA (Botox) injections. Botox is indicated for the treatment of chronic headaches in patients who have at least 14 headache days per month. In addition, Botox is a U.S. Food and Drug Administration (FDA) approved treatment for the treatment of migraines. The records provided for review document that this patient has been refractory to standard migraine medications. The records document that the patients frequency of migraines has improved from more than 15 headache days per month to five or six days per month with Botox. The patients occipital neuralgia is also likely to exacerbate her migraines. For these reasons, the requested Botox injections 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 neurology 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 patients parent has requested authorization and coverage for general anesthesia for the proposed dental procedures. The recent guidelines state that, at least two people with specific training and credentials should be present with a pediatric patient undergoing deep sedation or general anesthesia for dental treatment in a dental facility or hospital. The authors noted that, the sedation should be administered by a qualified anesthesia provider. In this case, the patient does not have a diagnosis of situation anxiety disorder in her medical records, nor is there evidence of any other behavior condition, which would make her cooperation during the procedure difficult. However, her dental provider has stated that the patient will need to undergo extensive restoration with tooth extractions and root canal procedures. These procedures will require general anesthesia to be provided by qualified anesthesia provider who is not performing the primary dental procedures. Based on the available records for review and the most recent guidelines, the requested general anesthesia for the proposed dental procedures 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Humira 40 mg every five days. The American Gastroenterological Association (AGA) guidelines for therapeutic drug monitoring recommend a Humira level of 7.5 ug/mL or higher (Feuerstein, et al.). This patients therapeutic drug monitoring revealed a Humira level of 7.7 mcg/mL. The Humira level in this case is adequate. The AGA guidelines recommend that in patients with a normal Humira level, low level of anti-Humira antibodies, and lack of objective inflammation, continue drug at current dose and look for other causes for symptoms. This patient has objective evidence of controlled Crohns disease on the current dose, with normal colonoscopy, and normal fecal calprotectin. Anti-tumor necrosis factor medications such as Humira can be associated with significant risks at standard dosing, and these risks may be elevated at doses higher than the U.S. Food and Drug Administration (FDA) approved dose. For these reasons, the requested Humira 40 mg every five days is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication dosage 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for spinal surgery consisting of two-level lumbar fusion (CPT codes 20937, 22630, 22632, 22842, 63047 and 63048). The records provided for review document that this patient has failed over five years of conservative, non-surgical treatment for management of her low back and radicular leg pain. Given her symptoms and failure of non-surgical treatment, surgery is an acceptable treatment option. The patients foraminal stenosis due to disc height loss supports the requested restoration of disc space height through placement of an interbody device, or with complete resection of the facet joint, which then results in iatrogenic instability and requires instrumentation and fusion. The patients primary back pain due to disc degeneration is unlikely to respond to decompression alone. Lumbar disc arthroplasty is not recommended for two levels of degenerative disc disease. Thus, a two level spinal fusion is the appropriate surgical intervention. All told, the requested spinal surgery consisting of two-level lumbar fusion (CPT codes 20937, 22630, 22632, 22842, 63047 and 63048) 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 neurological 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT) (CPT 77338 x 3, 77301 x 1, and G6015 x 25) at a dose of 79.2 Gray (Gy). This patient presents with prostate cancer. He has been treated with androgen deprivation therapy and his provider recommended IMRT. Researchers noted that IMRT is a curative treatment modality for localized prostate cancer. However, prospective data has yet to validate a role for IMRT in the treatment of metastatic prostate cancer. There is a paucity of data in medical literature to support a role for IMRT in the treatment of this patients prostate cancer. All told, the requested IMRT (CPT 77338 x 3, 77301 x 1, and G6015 x 25) at a dose of 79.2 Gy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested IMRT (CPT 77338 x 3, 77301 x 1, and G6015 x 25) at a dose of 79.2 Gy 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 urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of the hypoglossal nerve stimulator (CPT 64568, 95970, and 0466T). The patient has obstructive sleep apnea (OSA) without evidence of nasal obstruction. A drug induced sleep endoscopy (DISE) demonstrated primarily anterior posterior collapse and no concentric collapse at the velum. The patient has not been able to tolerate treatment with a continuous positive airway pressure (CPAP) device. The patient is a candidate for hypoglossal nerve stimulation given his intolerance to CPAP, anterior posterior collapse, and lack of central apnea. The patient has a BMI of 34 kg/m2. However, an elevated BMI over 32 kg/m2 does not preclude the patient from undergoing hypoglossal nerve stimulation as the surgery is successfully performed in patients with a BMI over 32 kg/m2. All told, the requested implantation of the hypoglossal nerve stimulator (CPT 64568, 95970, and 0466T) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested implantation of the hypoglossal nerve stimulator (CPT 64568, 95970, and 0466T) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in sleep medicine and is 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 magnetic resonance imaging (MRI) of the breasts (CPT code 77046). Use of breast MRI is a standard radiologic approach for the evaluation of breast abnormalities of a pathologic nature. Breast MRI is helpful for assessment of breast tumors including metastatic or primary tumors. This patient demonstrates follicular lymphoma status post prior bilateral mastectomy. The provider has recommended further evaluation with breast MRI. Prior evaluation with a positron emission tomography (PET) scan was negative, demonstrating that her follicular lymphoma is PET non-avid. Thus, repeat PET scan would not be of utility for imaging of her breast tumor. MRI has demonstrated superior imaging for PET-negative lymphomas compared to PET and contrast enhanced computed tomography (CT) imaging. Given these findings, the requested MRI of the breast (CPT 77046) is 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 requested MRI of the breast (CPT 77046) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is 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

An enrollees parent has requested authorization and coverage for excimer laser therapy. Current literature suggests that light therapy, in the form of excimer laser, is within the standard of care after the use of topical corticosteroids and calcineurin inhibitors. As this patient has failed treatment with topical steroids, tacrolimus ointment, and conventional NB-UVB, the requested excimer laser therapy is consistent with the medical literature. Given this support, the requested excimer laser therapy is 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 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 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: Overturned Decision of Health Plan

An enrollee has requested reimbursement for a purchase of tadalafil 5 mg tablets, and authorization and coverage for tadalafil 5 mg tablets, one pill per day. In men, lower urinary tract symptoms (LUTS) are primarily attributed to benign prostatic hyperplasia (BPH). Therapeutic options are targeted to relax prostate smooth muscle and/or reduce prostate enlargement. Medical literature states that major preclinical and clinical data concludes that tadalafil is effective both as a monotherapy and add-on therapy in patients with LUTS secondary to BPH. In addition to showing increasing efficacy for BPH and LUTS, daily tadalafil is also a commonly used oral drug treatment for clinically active Peyronies disease. In this case, the patient has LUTS secondary to BPH as well as a concurrent diagnosis of Peyronies disease. The use of tadalafil for this patient with these combined diagnoses is reasonable and appropriate. Accordingly, the tadalafil 5 mg tablets purchased by the patient were medically necessary to treat the patients medical condition, and tadalafil 5 mg tablets, one pill per day, are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that both the purchased medication and the requested medication are medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in urology 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 patients parent has requested authorization and coverage for hyperbaric chamber treatments. There is a paucity of peer-reviewed medical literature consisting of medical studies or trials demonstrating the benefit of hyperbaric oxygen therapy in patients with a diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Studies on hyperbaric oxygen therapy in patients with PANDAS or other neuropsychiatric syndromes have not demonstrated improved health outcomes. Swedo and colleagues noted that the therapeutic interventions are limited to symptomatic treatments, including medications and behavioral therapies. The authors found that selective serotonin reuptake inhibitors (SSRIs) have been shown to be beneficial for patients with PANDAS. All told, the requested hyperbaric chamber treatments are 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 internal medicine with subspecialty certification in pediatric allergy and  immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for laboratory testing at least three (3) times a year. This enrollee has a history of fatty liver, elevated alanine aminotransferase level, hypotestosteronism, for which he has testosterone implants, and asthma. The enrollee reports he used to have laboratory testing three times per year to monitor his medical conditions. The physician reports it is not necessary or helpful to recheck his cholesterol level more than annually. The enrollee is requesting laboratory testing at least three times per year as the levels fluctuate and he has modified his diet to improve results. His physician indicates that he only orders testing as medically indicated. There are no medical records of the enrollees face to face encounters with his treating provider.  The enrollee appears to want to relay his requests for blood work via email.  There are no medical records from the treating provider.  There are no recommendations in any current peer reviewed literature, or community standards of care, or clinical guidelines, including the guidelines published a governmental body, which suggest any blood or urine testing to be done without being evaluated properly by a treating provider.  To request blood testing quarterly, or three times annually, without a provider evaluation, is not appropriateFinal Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in family medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested authorization and coverage for genetic testing. The enrollee has Hashimotos thyroiditis, hypothyroidism, ulcerative colitis, high body mass index, and hyperlipidemia. She is on hormone replacement therapy. She has a family history of blood clots, coronary artery disease and respiratory failure. Literature reports the genetic status of at-risk family members without symptoms can be established with genetic testing, but the indications for testing of at-risk family members are unresolved. Without evidence that early identification of the Leiden variant leads to interventions that can reduce disease symptoms or death, decisions regarding testing should be made on an individual basis. Most guidelines consider such testing justified only for relatives of the first family member noted to have a lack of natural anticoagulants, or with multiple abnormalities.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Pain Management 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.