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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for implantation of a hypoglossal nerve stimulator. Findings: Two physician reviewers found that CPAP is the most common type of therapy for patients with severe OSA. Hypoglossal nerve stimulation therapy has been proven by the U.S. Food and Drug Administration (FDA) to be an effective modality of treatment of OSA in patients with tongue-based obstruction. The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult OSA syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Candidates for hypoglossal nerve stimulation includes patients who have failed, or are not candidates for CPAP or a dental device. Other criteria include an AHI between 15 and 65 on a recent sleep study, no more than 25 percent central apneas (including mixed), and a body mass index (BMI) of 35 or less. This patient continues to manifest obesity with a BMI over the criteria. Specific to this patients case, there are standard interventions that are likely to be more effective than the requested procedure. In addition, alternative therapy was not documented in the current clinical records. All told, the requested implantation of a hypoglossal nerve stimulator is not likely to be more beneficial than standard available therapies for treatment of this patients medical condition. One reviewer concluded that the requested implantation of a hypoglossal nerve stimulator 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 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:  One reviewer is board certified in otolaryngology and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology 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

A patient has a medical history that is significant for primary ciliary dyskinesia with bronchiectasis. At issue in this case is whether the requested high frequency chest wall oscillation system (SmartVest Airway Clearance System) is medically necessary for treatment of the patients medical condition. High frequency chest wall oscillation was developed to improve airway clearance in patients when the normal mucociliary transport system has failed, as with bronchiectasis. In this case, the patient has been compliant with all recommended interventions. She was initially prescribed an Aerobika for airway clearance, and despite routine frequent use, her pulmonary function declined and she remained symptomatic. The provider initiated vest therapy, with improvement in clinical symptoms, and no further decline in pulmonary function testing.Final Result: The reviewer determined that the requested device 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 pediatrics with subspecialty certification in pediatric 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 parent of an enrollee has requested authorization and coverage for intensive home-based feeding therapy.Feeding problems are a common childhood complaint, and in some children may be severe enough to result in growth failure and susceptibility to illness. Feeding problems are particularly common in patients who are developmentally delayed. Patients with autism frequently have oral aversions due to taste, texture, and presentation. While these children are not typically failing to thrive, the restricted diet can lead to nutritional deficiencies, which in some cases can be quite severe. Patients may acquire micronutrient deficiencies as well as macronutrient deficiencies. Some patients may limit liquid, leading to dehydration. In this patients case, the records document severe oral aversion and restricted eating. He is likely malnourished because of the restrictive nature of his diet. In addition, he will only take one type of liquid which is no longer being manufactured. Fluid restriction will lead to severe dehydration unless it is aggressively addressed. The patient has participated in two feeding programs, and both failed to resolve his feeding difficulties. He now requires an intensive feeding program. An in-home program is necessary because it incorporates all aspects of the patients environment. Therefore, the requested intensive home-based feeding therapy 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 pediatrics 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: At issue in this case is whether the requested Epclusa 400mg -100mg for 12 weeks is medically necessary to treat the patients medical condition. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to nonliver-related conditions. This patient has liver nodularity consistent with cirrhosis on imaging, as well as concern for ascites, an indicator of decompensated cirrhosis. However, the Epclusa regimen requested is not sufficient for the patients clinical presentation. The AASLD/IDSA guidelines recommend that treatment-naive genotype 1 patients with decompensated cirrhosis should be treated with Epclusa and ribavirin for 12 weeks, based on the ASTRAL-4 trial. The guidelines state that if ribavirin is not used, Epclusa must be used for 24 weeks. For these reasons, although treatment of hepatitis C is needed, the requested treatment with Epclusa 400mg -100mg for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is requesting Dupixent. Findings:  The physician reviewer found that because of the lack of previous treatment with topical calcineurin inhibitors, he does not meet the guidelines or the FDA indication for the use of Dupixent. Guidelines for management of moderate-to-severe atopic dermatitis include the use of topical corticosteroids and/or topical calcineurin inhibitors. The U.S. Food and Drug Administration (FDA) indication for Dupixent is for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies, or when those therapies are not advisable. In this case, the patient has moderate-to-severe atopic dermatitis that was refractory to topical corticosteroids in the past. However, the patient has not been treated with topical calcineurin inhibitors. Because of the lack of previous treatment with topical calcineurin inhibitors, he does not meet the guidelines or the FDA indication for the use of Dupixent. As such, the medication Dupixent is not medically necessary for treatment of the patients medical condition. 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the bilateral balloon sinuplasty of the frontal, maxillary and sphenoid sinuses (CPT 31295 x 2 and 31298 x 2) that was performed. The Health Plan has denied the service at issue as experimental or investigational for treatment of the enrollees chronic rhinosinusitis (CRS).Findings:  Two out of three physician reviewers found that According to the American Academy of Otolarygology-Head and Neck Surgery (AAO-HNS) official policy statement, sinus ostial dilation (e.g. balloon ostial dilation) is a therapeutic option for selected patients with CRS who have failed appropriate medical therapy. Clinical diagnosis of CRS should be based on symptoms of sinusitis and supported by nasal endoscopy documenting sinonasal abnormality or mucosal thickening on CT of the paranasal sinuses. The records state that he was treated with maximal medical therapy prior to the CT scan. He had been treated in several urgent care centers and also with an extended course of antibiotics. However, there was only evidence of sinus disease in the right frontal sinus and the sphenoethmoid recess. There was opacification of the posterior ethmoids. The maxillary sinuses, ostiomeatal complex, left frontal, and the sphenoid were clear. One physician reviewer found that the medical record did not confirm an etiology of chronic sinus disease. Final Result: The reviewers determined that the balloon ostial dilation procedure of the right frontal and sphenoid sinuses (CPT 31298 x 1) that was performed was likely to be more beneficial than any available standard therapy. However, the balloon ostial dilation procedure of the left frontal and sphenoid sinuses (CPT 31298 x 1) and maxillary sinuses (CPT 31295 x 2) were not likely to be more beneficial 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 otolaryngology 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: At issue is whether for the Optune device that was rented was likely to have been more beneficial for treatment of the patients condition than any available standard therapy. Findings:  Three physician reviewers found that a review of the record indicates that the patient presented to the emergency department with complaints of a headache associated with dizziness, nausea, vomiting, photophobia and fatigue. He underwent radiographic imaging that revealed a large frontal mass on the right side with swelling and compression noted. The patient was diagnosed with glioblastoma multiforme. He subsequently underwent a craniotomy followed by chemo-radiation treatment.The medical literature supports the use of an Optune device for the treatment of glioblastoma. The National Comprehensive Cancer Network (NCCN) guidelines include an Optune device as a treatment option for patients as adjuvant therapy. The U.S. Food and Drug Administration (FDA) has approved Optune. Current evidence supports the use of TTFs as an efficacious, antimitotic treatment with minimal toxicity in patients with newly diagnosed and recurrent GBM.Final Result: Three out of the three reviewers determined that the requested device was likely to have been 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 internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee was diagnosed with right sacroiliac (SI) joint pain. The patient was injured in a motor vehicle accident. The patients provider recommended a right sacroiliac joint injection, as she had symptoms and findings consistent with SI joint pain. At that time, her pain was rated as 2 to 3 out of 10. She underwent a right SI joint injection under fluoroscopy. She returned to the neurosurgeon and reported that her pain was a 3 to 7 out of 10 at that time, and she was unsure of whether the injection helped, as she had been quite inactive afterwards, and the pain was low following the injection. The provider recommended a repeat SI joint injection under computed tomography (CT) guidance. The patient returned to her provider and she reported her pain as having improved to a 1 out of 10.  The patient has requested authorization and coverage for sacroiliac joint injection. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.At issue in this case is whether the requested right sacroiliac joint injection is medically necessary for treatment of this patients medical condition. According to the appropriate use criteria for fluoroscopically guided diagnostic and therapeutic sacroiliac interventions, pain should be at least a 4 out of 10 before the injection, in order to be able to properly assess efficacy after the injection. Injections are considered appropriate for pain of lesser intensity and duration if the pain is causing functional limitation and conservative treatment has been provided.  In this case, the patient rated her pain as 1 out of 10 and reported no functional limitation.  Thus, there was no reason to pursue treatment of mild or non-existent pain. If the pain were to return, and the symptoms and signs point to SI joint as the responsible pain generator, then an injection may be appropriate. Therefore, the requested right sacroiliac joint injection is not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether Breast Cancer Index (BCI) provided was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.The medical literature supports the use of the Breast Cancer Index (BCI) as prognostic for recurrence and when considering extended therapy. Studies have validated the BCI as an accurate predictor of endocrine responsiveness among patients with estrogen receptive (ER)-positive breast cancer, with one case-control study suggesting it may identify those who would benefit from extended endocrine therapy. The American Society of Clinical Oncology (ASCO) supports the use of the BCI. The NCCN guidelines also support use of BCI in women with node-negative disease. This patient is lymph node negative and meets criteria for testing with BCI. Final Result: Two of the three reviewers determined that the requested Breast Cancer Index was likely to have been 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology, and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the DecisionDx-Melanoma test that was received. The Health Plan has denied the service at issue as investigational for patients with melanoma.Findings:  Three physician reviewers found that the American Society of Clinical Oncology (ASCO) and Society for Surgical Oncology guidelines recommend sentinel lymph node (SNL) biopsy for patients with intermediate thickness cutaneous melanomas with Breslow thickness 1 to 4 mm of any anatomic site. Routine use of SNL biopsy in this population provides accurate staging, with high estimates for proportion successfully mapped and acceptable estimates for false-negative rate, post-test probability negative and predictive value positive. The patient was assessed with a Breslow thickness 3.2 mm melanoma tumor. The most appropriate test to determine the prognosis related to the patients diagnosis of a malignant melanoma was an SNL biopsy. The use of DecisionDx-Melanoma testing is not the appropriate next step for determination of risk of recurrence and prognosis in a patient with undetermined lymph node status. The record does not indicate that the patient was ineligible for SNL biopsy. The DecisionDx-Melanoma molecular test does not substitute for the determination of risk of sentinel node positivity. Thus, the DecisionDx-Melanoma test received on was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 internal medicine with subspecialty certification in medical oncology, 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 authorization and coverage for Humira pen injector. Findings:  The physician reviewer found that the American Academy of Dermatology guidelines for the management of psoriasis includes topical therapy as first-line treatment. If ultraviolet treatment is not available, other first-line treatments include acitretin, adalimumab, cyclosporine, etanercept, infliximab, methotrexate and ustekinumab. In this case, the patient has used topical clobetasol for her scalp psoriasis, but her provider described it as ineffective. The provider has recommended Humira because the patient is of childbearing potential and is considering starting a family. Humira has not been proven to be safe in pregnancy. Humira is pregnancy category B, which means that animal reproduction studies have failed to demonstrate a risk to the fetus, and there are no adequate and well-controlled studies in pregnant women. Since the patient has only been treated with topical clobetasol, and Humira has not been proven to be safe in pregnancy, the requested medication is not medically indicated. Therefore, Humira pen injector 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for intraoperative radiation therapyFindings:  Two of the three physician reviewers found Intraoperative radiation therapy is considered a standard treatment in this patients case. Accelerated partial breast irradiation is considered an acceptable treatment for patients with early stage breast cancer meeting stringent criteria. Accelerated partial breast irradiation may be delivered using external beam radiotherapy, brachytherapy, or intraoperative radiation therapy. The trial noted equivalent four-year local control rates between intraoperative radiation therapy and external beam whole breast radiotherapy, and colleagues noted that toxicity was lower in the intraoperative radiotherapy group than in the external beam radiation therapy group. In sum, intraoperative radiation therapy is likely to be more effective than other treatment options. 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 radiation oncology 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.