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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for onabotulinumtoxinA (Botox) injections every three to four months for the duration of one year for treatment of the enrollees neck pain.  Findings:  The physician reviewer found that Botox A has been used for myofascial pain with some recent evidence. However, most of the clinical evidence does not support or is inconclusive for the use of botulinum toxin for myofascial pain. In this patients case, not all non-botulinum toxin treatment options have been utilized or documented. While pain psychology group therapy was noted to be done for mood control, there was no mention of individual behavioral therapy for pain, in the form of cognitive behavior therapy or bio feedback, despite much research to support its use. In addition, the submitted documentation does not indicate that all non-botulinum toxin medications have been optimized or documented to be done. Moreover, the treating providers offered interventional treatments for this patients pain. It was noted in the past that the pain source may be the facet joints, which has great research to support treating facet pain with injections and/or radiofrequency ablation.  Based on the records and medical literature, not all evidence based interventional treatments have been tried for treatment of this patients pain. For all these reasons, the requested authorization and coverage for Botox injections every three to four months for the duration of one year, has not been demonstrated as medically necessary for treatment of this 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for CyberKnife treatment stereotactic body radiotherapy (SBRT). Findings:  The physician reviewer found that upon review of the available data, the use of SBRT for patients with very high risk prostate cancer is not supported. Outcome data for SBRT at this time is limited to five to six year follow up, and limited to patients with low risk or favorable intermediate risk disease. The most recent guidelines support the use of SBRT in treating low risk or favorable intermediate risk. However, studies on SBRT in higher risk groups are lacking. Thus, guidelines do not support the use of SBRT for patients who are considered very high risk due to seminal vesicle involvement on MRI. Therefore, in this patients case, CyberKnife treatment SBRT is not likely to be more effective than the available methods of treating this patients medical condition. Final Result: All three reviewers have determined 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:  All three reviewers are board certified in radiation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block therapy. Findings:  Three physician reviewers found that neuralgia is a type of neuropathic pain. Occipital neuralgia specifically refers to pain or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. In this case, the patient had evidence of occipital neuralgia on examination. The treatment of choice for occipital neuralgia is a local occipital nerve block due to its ability to relieve pain and act as a diagnostic marker. The medical evidence supports the services at issue in this clinical setting. Therefore, occipital nerve block therapy 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 neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oral device E0486. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees sleep apnea.In this case, the patients clinical presentation indicates a diagnosis of OSA based on current diagnostic standards in the International Classification of Sleep Disorders. The enrollee is also noted to have clinically significant excessive daytime sleepiness on the basis of her Epworth sleepiness scale score. According to recently published joint practice guidelines from the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine, the use of oral appliance therapy is generally accepted for patients who are intolerant of CPAP. In this patients case, it has been demonstrated that she meets the recommended criteria for oral appliance therapy. For these reasons, the oral device, E0486 is medically necessary.Final Result: The reviewer determined 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 neurology with sub-specialty certification in sleep medicine and 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: A patient has requested authorization and coverage for reduction mammoplasty. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients macromastia and are not reconstructive in nature. This patient has well-documented chronic back and neck pain as well as shoulder grooving. This has significantly impacted the patients daily activities. The patients condition of macromastia is causing functional problems, and the patient is likely to benefit from reduction surgery. In this patients case, the requested reduction mammoplasty is consistent with standard of care. The patient has a functional problem that is directly related to significant macromastia. Breast reduction is a well-known procedure that directly addresses this functional deficit. Therefore, the requested reduction mammoplasty is medically necessary for the treatment of this patient.Based on the records provided, the patients condition constitutes an abnormal structure of the body. The patients photographs show evidence of significant macromastia, resulting in an abnormal enlargement of the breasts. This can be considered a developmental abnormality, as this has increased despite previous breast reduction. The requested services are likely to improve function, as the patient has chronic pain from this condition. Additionally, the requested services are likely to create a normal appearance to the extent possible. Based on the photographs, the requested services are likely to provide more than a minimal improvement in appearance. In sum, the requested reduction mammoplasty is reconstructive in nature.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 plastic 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). Findings:  Three physician reviewers found that this patient presents with locally advanced prostate cancer. The patient underwent surgery and his provider has recommended additional treatment with adjuvant radiation therapy. Adjuvant radiation therapy can be delivered using three-dimensional (3D) conventional radiation therapy or IMRT. In postoperative situation, IMRT is preferred to 3D conventional radiation therapy as IMRT can deliver the prescribed high dose of radiation therapy and can achieve the constraints for nearby organs at risk, especially the bowels. In addition, the American Urological association guidelines also recommend adjuvant radiation therapy for stage III patients. Given this support, the IMRT services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the IMRT services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical therapy services. The submitted documentation fails to demonstrate the medical necessity of the requested services. Close therapist supervision and guidance can be important in the initial stages of a rehabilitation program for shoulder symptoms due to rotator cuff tears. However, long-term skilled physical therapy, including supervised exercises, modalities and formal manual therapies/modalities, is not of proven benefit in this clinical scenario. As range of motion and strength are restored and the patient becomes accustomed to the exercises, the program can be transitioned to an independent program. In this case, although the patient has persistent symptoms, further physical therapy would not reasonably be expected to favorably impact the clinical or functional outcomes or course. The records do not support the medical necessity of additional skilled exercise supervision. There is a lack of proven marginally significant benefit of formal manual therapy or other formal passive palliative modalities over palliative measures that can be applied independently. All told, the requested physical therapy 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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. Findings:  Two of the three physician reviewers found breast MRI has an important role in both screening and diagnostic settings. There are multiple clinical considerations in which MRI has become widely used. These include areas of asymmetry, architectural distortion, and distinguishing tumor recurrence versus scarring. Breast MRI may be a useful adjunctive tool when conventional imaging findings are equivocal, as in this clinical setting. The Health Plan has noted that an MRI should not replace a biopsy in clear-cut masses. However, in this patients case, it is unclear whether she actually has a mass. While a breast MRI should not be a substitute for a biopsy for a clearly defined tumor, the provider must be able to localize the most suspicious area to best direct a biopsy. An MRI can direct the biopsy and further exclude a tumor. Therefore, the requested MRI is likely to be superior over other available methods of evaluating this patient. 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 reviewers 1, 2 and 3 are board certified in diagnostic radiology 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 authorization and coverage for subcutaneous implantable cardioverter-defibrillator (S-ICD). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has a history of non-sustained ventricular tachycardia.Findings:  The records indicate that this patient had a normal electrocardiogram tracing during episode of syncope, which occurred while having the implantable loop recorder. Prior work up showed no evidence of structural heart disease. In order to qualify for S-ICD the patient needs to have met criteria for a standard ICD and then have some reason why the subcutaneous model is preferred (such as lack of veins or immunocompromised state). Based on the documentation provided, this patient does not meet the standard ICD criteria. Low ejection fraction has not been diagnosed and no structural heart disease or congenital conduction defect has been shown.  As such, the need for an ICD or an S-ICD has not been demonstrated according to the information available to date. Accordingly, S-ICD placement is not likely to be of greater benefit than the available standard therapy for treating this patients medical condition. Final Result: Two of the three reviewers have determined 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for botulinum toxin injections for treatment of the enrollees chronic pelvic pain syndrome. Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Botulinum toxin bladder injection therapy is considered a safe and effective option for patients with interstitial cystitis and bladder pain syndrome. This treatment may be of particular benefit for patients with significant irritative urinary symptoms associated with bladder cycling. This patient has failed multimodal therapy. Therefore, she was an appropriate candidate for salvage therapy using Botox injections. In sum, botulinum toxin injections were likely to have been of greater benefit than other treatment options. Final Result: Two of three 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 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 reimbursement for the F5 (coagulation factor V) hereditary hypercoagulability gene analysis.  Deep vein thrombosis and pulmonary embolism may be caused by hereditary thrombophilias. In the clinical setting of increased risk, complications may be prevented by appropriate interventions. There is strong medical evidence supporting factor V Leiden testing in this patients case. The testing as ordered was appropriate in order for preventative measures to be implemented for this patient to help prevent potential complications. Given this support, the F5 (coagulation factor V) hereditary hypercoagulability gene analysis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that Final Result: Two of the three reviewers determined that the testing 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 overturned. Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 dual x-ray absorptiometry (DEXA). The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition.Trabecular bone score (TBS) is a recently developed analytical tool that performs novel grey level texture measurements on lumbar spine dual x-ray absorptiometry (DEXA) images, and thereby captures information relating to trabecular microarchitecture. The medical literature indicates that this technique adds information to bone mineral density. TBS has been shown to have predictive value for fracture independent of fracture probabilities using the FRAX algorithm. The National Osteoporosis Foundation guidelines indicate that patients taking U.S. Food and Drug Administration approved medications should have laboratory and bone density re-evaluation after two years or more frequently when medically appropriate, which is the case with this patient. Per the National Osteoporosis Foundation guidelines, a DEXA scan to assess the effectiveness of medical therapy at two years or more frequent intervals, is medically appropriate in this clinical setting.  In sum, based on the current medical literature as well as the documentation provided, the requested DEXA scan has been demonstrated as medically necessary for the evaluation 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and expertise in transgender care 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.