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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for excimer skin laser therapy two (2) times weekly. Several studies show the benefits of excimer laser therapy when first-line treatments have failed. Researchers found that excimer laser therapy can safely and effectively be used in the treatment of the prurigo form of atopic dermatitis, and for the long-term, may be an option in the case of therapy-resistant patients. Scientists noted, Phototherapy is a second-line treatment for moderate to severe atopic dermatitis that effectively decreases cutaneous inflammation with minimal or no systemic side effects. Researchers noted that, excimer laser and excimer lamp might be the best option for clearing localized therapy-resistant lesions. Studies found that excimer light treatment significantly changed the composition of the bacterial microbiome in the lesional skin of atopic dermatitis, possibly leading to improvement. In this case, the patients dorsal foot eczema was described as thick, had been present for 15 years, and had failed multiple therapies. The condition had not responded to a potent topical steroid, clobetasol, applied with wet wraps. Due to her pregnancy, the patient is a poor candidate for systemic therapy, and excimer laser therapy in addition to a strong topical steroid regimen is likely the safest treatment option. Therefore, the requested excimer skin laser therapy two (2) times weekly is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two out of three medical experts decided that excimer skin laser therapy two (2) times weekly 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a high frequency chest compression device (HCPCS E0483). The goal of therapy for patients with bronchiectasis is to improve airway mucus clearance. In this case, the patient has progressive bronchiectasis despite adherence to a daily mucous clearance program and use of an acapella flutter valve. Given the persistent and progressive nature of the patients disease, escalating therapy from daily hypertonic saline nebulizer and acapella flutter valve to a high frequency chest compression device represents standard practice. Therefore, a high frequency chest compression device (HCPCS E0483) is medically necessary for the treatment of this patient.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 internal medicine with sub-specialty certification in pulmonary disease and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a right ear hearing aid. There is a lack of consensus on the criteria for hearing aid candidature and variability in the use of hearing aids in clinical practice among patients with mild hearing loss. In a study to assess the long-term effectiveness of interventions to promote the use of hearing aids, Barker and colleagues found that There was no evidence of a statistically or clinically significant effect on hearing handicap, hearing aid benefit or the use of verbal communication strategies in the short to medium term. In this case, the patient has normal hearing in her right ear, with a speech reception threshold of 10 dB, indicating that she can hear 50% of the words at a 10 dB level, which is quieter than a whisper, and 100% word discrimination at conversational speech levels. Therefore, a right hearing aid is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 otolaryngology 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 consultation with a cardiologist that specializes in adult congenital heart disease. This patient has a congenital ventricular septal defect and a strong family history of severe complex congenital heart disease including a familial hypertrophic cardiomyopathy. Her care has been maintained at a congenital heart disease clinic since she was a child. She has requested to have a consultation with an adult congenital heart disease specialist. The requested consultation is appropriate given her personal history of ventricular septal defect and strong family history of congenital heart disease. Given the patients known history of congenital heart disease, complex family history and familial genetic cardiomyopathy, consultation with an adult congenital heart disease specialist is appropriate. An adult interventional cardiologist is less versed in the care of congenital defects, especially given the complexity and severity of the genetically transmitted familial heart disease involved in this patients family. Given these findings, the requested consultation with a cardiologist that specializes in adult congenital heart disease is medically necessary for this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease 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 hyperbaric oxygen chamber treatment and retrograde urethrogram. This patient has a history of prostate cancer and he presents with radiation cystitis. His clinical outcome after radiation is the source of continued distress. In 2019, the patient required fulguration for bleeding and overactive bladder. His provider has recommended a retrograde urethrogram, which would be helpful to show the character of the channel. In addition, a retrograde urethrogram will not subject the patient to repeated endoscopy, which is likely to traumatize the urethra and cause scarring and subsequent obstruction. Evaluation with retrograde urethrogram is indicated to locate a possible area for therapeutic intervention given his significant PVR. For these reasons, the requested retrograde urethrogram is medically necessary for this patient. Based on current medical literature, the patients radiation cystitis warrants an attempt at symptomatic relief with hyperbaric oxygen chamber treatment. Villeirs and colleagues found that, Hyperbaric oxygen therapy is effective in the treatment of radiation-induced cystitis, with minimal adverse events. Researchers reported that of the 602 patients across 13 studies evaluated, 84% experienced partial or complete resolution of hemorrhagic radiation cystitis with hyperbaric oxygen therapy. There is a lack of other therapeutic options without a fixed obstructive site that are of equal or superior benefit to hyperbaric oxygen therapy in this patients clinical setting. Accordingly, the requested hyperbaric oxygen chamber treatment is medically necessary for this patient. All told, the requested hyperbaric oxygen chamber treatment and retrograde urethrogram are medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation and 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 patient has requested authorization and coverage for oxycodone HCl 30 mg IR (immediate release) tablets, 270 tablets per 30 days. The Centers for Disease Control and Prevention (CDC) guidelines for the prescribing of opioids for chronic pain state that providers should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. Similarly, the Federation of State Medical Boards guidelines state that, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. In this case, the patient was diagnosed with CRPS after being injured in a dog attack. Her treatment planning has included pain management, which recommended ganglion blocks and opioid therapy. She has also received ketamine infusions in the past with short-term benefit. The records do not document usage of pain scores demonstrating at least 30% analgesic benefit with her medication regimen or signs of validated functional assessment scales to support functional improvement. In addition, there is a lack of regular urine drug screens as recommended by national guidelines. The notes from December 2019 suggest that the patient has experienced side effects of constipation and abdominal pain, likely due to high-dose opioid therapy. Based on the available medical records for review and current guidelines, abrupt discontinuation of high-dose chronic opioid therapy would place this patient at risk for symptoms of withdrawal. Given these findings, oxycodone 30 mg every eight hours as needed, 90 tablets per days, is medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 surgery to remove a nabothian cyst and endometrial polyp. Nabothian cysts have a distinct appearance and are a common finding on pelvic examination. The cysts vary in size and although most lesions are asymptomatic, some may cause vaginal discomfort. These lesions are unlikely to cause pelvic pain and typically do not require treatment. In limited clinical settings when treatment is indicated, first-line options include draining or ablation of the cyst. Based on current data, surgical removal of a nabothian cyst is not considered a first-line modality, and can cause scar tissue leading to dyspareunia or cervical stenosis. With regard to the patients endometrial polyp, there is a lack of evidence on imaging that this polyp is still present. Furthermore, polyps are typically associated with abnormal vaginal bleeding, which is not documented in this patients records. Given these findings, the requested surgery to remove a nabothian cyst and endometrial polyp is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 transperineal placement of a SpaceOAR Hydrogel (CPT 55874). The requested transperineal placement of SpaceOAR Hydrogel (CPT 55874) is currently considered standard of care in the radiation oncology community for use in this patients clinical setting. The recent NCCN guidelines support the use of SpaceOAR Hydrogel based on the results of a high quality phase 3 prospective clinical trial, which revealed significantly improved benefit in terms of bowel, urinary and sexual toxicity with the SpaceOAR system, as compared with similar dose-escalated radiation without use of the SpaceOAR system. The authors reported that the displacement created by SpaceOAR between the prostate and the rectum effectively results in improved patient health outcomes. This patient presents with Gleason 3+4=7 in the right base with 67% tumor involvement and the presence of perineural invasion and Gleason 3+3=6 in the left apex with 67% involvement. His provider has recommended radiation therapy with use of the SpaceOAR Hydrogel perirectal spacer. Given the support in the peer-reviewed medical literature and guidelines, the requested transperineal placement of a SpaceOAR Hydrogel (CPT 55874) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested transperineal placement of a SpaceOAR Hydrogel (CPT 55874) 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for home infusions of Privigen 10%, 190 grams infused over three days every four weeks for three cycles. Standard treatment of small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain. In small fiber neuropathy, current neuropathic pain treatment options are generally insufficient to control the pain. Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. IVIG is supported as a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. IVIG has been used with significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are most often small fiber polyneuropathies. In a retrospective study by researchers, 55 patients with confirmed small fiber polyneuropathy attributed to autoimmunity received IVIG for more than three months. The authors reported that 74% of patients rated themselves as improved, treating providers labeled 77% of patients as IVIG responders, and 16% of patients entered remissions that were sustained after the completion of IVIG. The authors concluded that the results provide Class IV evidence suggesting that IVIG is safe and effective for rigorously selected small fiber polyneuropathy patients with apparent autoimmune causality. In this case, the patient has debilitating small fiber neuropathy with laboratory evidence of autoimmunity. He has been treated with conventional medical therapy without substantial improvement. Based on the current peer-reviewed medical literature, patients with autoimmune small fiber neuropathy may improve clinically with IVIG. Accordingly, the requested home infusions of Privigen 10%, 190 grams infused over three days every four weeks for three cycles is 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 home infusions of Privigen 10%, 190 grams infused over three days every four weeks for three cycles 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transperineal placement of a SpaceOAR Hydrogel (CPT 55874). Modern radiotherapy employs dose escalation to maximize efficacy. Since the rectum lies in close proximity to the prostate, the risk of rectal toxicity is high without the use of a perirectal spacer. The use of SpaceOAR Hydrogel is considered standard of care per the current peer-reviewed medical literature in this patients clinical setting. One prospective randomized controlled trial demonstrated that the use of SpaceOAR in conjunction with radiation delivery significantly decreased bowel, urinary, and sexual morbidity as compared with radiation treatment without the use of SpaceOAR. Moreover, the recent NCCN guidelines for the management of prostate cancer support the utility of perirectal spacers to reduce high-grade acute and late rectal toxicity. This patient has no evidence for transcapsular extension, which is a contraindication to SpaceOAR use. Therefore, the requested transperineal placement of a SpaceOAR Hydrogel (CPT 55874) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested transperineal placement of a SpaceOAR Hydrogel (CPT 55874) 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for amphotericin B powder compound vaginal suppository. This patient has been evaluated with multiple cultures, which demonstrated the presence of candida albicans. Per the clinical documentation, she experienced a relief of symptoms with fluconazole with subsequent recurrence. Additional treatment has included voriconazole, which was associated with blurry vision, and posaconazole, which was discontinued due to a lack of efficacy. Multiple vaginal cultures have shown candida albicans with sensitivity to fluconazole. The candida was not sensitive to amphotericin B. There is limited evidence that amphotericin B has been used to some benefit in patients with candida glabrata, but these findings have not been reported in candida albicans. Standard treatment options for recurrent vulvovaginal candidiasis include topical or oral clotrimazole, Miconazole, tioconazole, gentian violet, or boric acid suppositories. There is a lack of documentation that the patient has undergone adequate trials with these conventional therapies. Therefore, the requested amphotericin B powder compound vaginal suppository 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 amphotericin B powder compound vaginal suppository 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 medication is 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 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.