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 tadalafil 10 mg tablets. The submitted documentation fails to demonstrate the medical necessity of the requested medication. A study found while tadalafil is a potential treatment for lower urinary tract symptoms associated with benign prostatic hyperplasia, it is not considered a first-line therapy. Following failure of alpha adrenergic blockade for documented symptomatology or measured abnormalities of voiding function, a trial of 5-alpha-reductase inhibitors may be appropriate. In this patients case, the records do not definitely document lower urinary tract symptoms related to benign prostatic hyperplasia. Thus, tadalafil 10 mg tablets are 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in the right knee. Evidence from systematic reviews and randomized controlled trials indicate that viscosupplementation may relieve knee pain in some patients with osteoarthritis. However, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) report that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS recommends reservation of viscosupplementation for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. The patient previously obtained excellent relief from viscosupplementation. She has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. As such, Orthovisc injections of the right knee are and medically necessary for management of this patients osteoarthritis. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for Guardant360 panel testing to determine the molecular status of her lung cancer and to guide next steps in medical treatment, accordingly. The enrollee is diagnosed with non-small cell lung cancer, with bone metastases. A right lung biopsy showed her cancer was epidermal growth factor receptor positive (EGFR) positive. A computerized tomography (CT) scan showed stage IV lung cancer with a mass and pulmonary nodules consistent with disease progression. Her primary adenocarcinoma was being treated with Tarceva and bone metastases were treated with Zometa. On an oncology visit, notes indicate her primary cancer had progressed with Tarceva treatment and the next step was to check for her TM 790 mutation, which would determine the course of her treatment. The Guardant360 panel genetic testing was performed and detected six total somatic alterations and a TM 790 value of 9.3. This diagnostic is a blood-based liquid biopsy that analyzes circulating tumor DNA (ctDNA). It is still in the research phase and is not the standard of care. Testing methods used to detect circulating cancer cells in enrollees with advanced non-small cell lung cancer is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines.  Literature shows that such testing can provide more specific information for secondary and last-line treatments, but there are not enough studies to support the utility of this type of testing in place of more specific genome testing.  The Guardant360 is promising technology, but one which still requires additional research and clinical trials. The validity of certain types of liquid biopsy methodologies for guiding treatment and predicting outcomes; however, the Guardant360 is not among those approved for use. 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 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:  The enrollee has requested authorization and coverage for acupuncture. The enrollee has a left heel spur and history of bunion surgery. She has a diagnosis of plantar fasciitis with throbbing pain when she is standing in one place and walking. It prevents her from doing her everyday activities. Findings:  The physician reviewer found that the enrollee wears orthotic shoes and applies heat with Epsom salt baths to alleviate pain. She has had cortisone shots, physical therapy, exercises, foot massage and medications. She was referred for acupuncture as her pain level was 10/10 and she was limping with a poor quality of life. The enrollee indicates the acupuncture has been successful to manage pain. However, there is a lack of peer-reviewed literature to support the safety and long-term efficacy of acupuncture for this enrollee's diagnosis. Results from a number of studies suggest acupuncture may help ease types of pain that are often chronic, such as low-back pain, neck pain, and osteoarthritis/knee pain. It also may help reduce the frequency of tension headaches and prevent migraine headaches. Two articles address the use of acupuncture for the relief of heel pain with high significant outcome. However, these are based on small samples and lack evidence supporting the use of the acupuncture for plantar fasciitis.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications:  The reviewer is board certified in acupuncture 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a rhinoplasty procedure.This patient had a history of trauma to his nose, which caused nasal obstruction. His preoperative images show deviation of the external nose and depression of the nasal bone. Functional nasal reconstruction is a commonly performed procedure that involves septal and middle/upper nasal vault surgery. The submitted documentation supports the medical necessity of the services at issue. Therefore, the rhinoplasty procedure was medically necessary for the treatment of this patient. In this patients case, the records document an abnormal structure of the body. As noted above, there was deviation of the external nose and depression of the nasal bone. This abnormal structure of the body was caused by trauma approximately one year prior. The services at issue were performed to improve nasal breathing. Therefore, the surgery was performed to improve function. Thus, the rhinoplasty procedure was reconstructive in nature. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition and were reconstructive in nature. Therefore, the Health Plans denial should be overturned. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement, authorization. and coverage for PhysioStim bone growth stimulating device. Findings:  The physician reviewer found that the requested service is not medically necessary for the treatment of the enrollees medical condition. The enrollee injured her left wrist and complained of continued pain, weakness and occasional numbness to the left hand and fingers. An x-ray indicated a fracture of the proximal pole scaphoid with sclerotic margins. A second x-ray demonstrated chronic non-union of the scaphoid. An open reduction internal fixation (ORIF) of the scaphoid non-union, with vascularized bone graft, and scapha capitate pinning were performed. At a follow-up appointment, the physician noted persistence of the non-union. He fitted the enrollee for a bone stimulator to help stimulate bone healing. The medical literature indicates the evidence is lacking for the treatment of nonunion scaphoid fractures with bone growth stimulation. While literature supports the use of stimulation to treat long-bone delayed unions or nonunions, its effectiveness on short bones, such as the scaphoid is lacking. The idea of using electric stimulation in the treatment of nonunion fractures dates back many years and from this, alternative healing methods using electricity, such as extracorporal shock wave therapy and ultrasound were developed to accelerate the healing process of fresh fractures and to treat delayed unions. However, despite these available methods, there has been limited literature that supports its use. Rather, literature indicates that bone healing is a complex metabolic process that can be hindered by excessive early motion of the fracture site, inadequate fracture reduction or fixation, contamination or infection of the fracture site, and patient-specific factors or co-morbidities. The medical literature does not support bone stimulation as the means of correcting nonunion of the scaphoid. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is board certified in hand 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for dry needling acupuncture for a history of perineal pain. A urology consult determined it was perineal pain of unclear etiology; possibly perineal muscle spasm or strain. The diagnosis was adductor strain and treatment included an exercise program and additional therapy sessions. Findings:  The physician reviewer found that dry needling acupuncture is the practice of acupuncture, and is used within the management of trigger point versus selection of a specific acupuncture point in management of neuropathic pain. Dry needling acupuncture is not medically necessary for management of pudendal neuralgia (PN), given the condition is neuropathic pain versus management of a specific trigger point.  Acupuncture, as a procedure, is the stimulation of anatomical locations on the body, alone and in combination, to treat disease, injury, pain, and dysfunction and to promote health and wellness. Acupuncture, includes the invasive stimulation of said locations by the insertion of needles and the non-invasive stimulation of said locations by thermal, electrical, chemical, light, mechanical or other manual therapeutic methods. Trigger point dry needling, dry needling, functional dry needling, and intramuscular manual therapy, or any other pseudonym describing acupuncture procedures, are, by definition, the practice of acupuncture. The specific effect of acupuncture on chronic prostatitis/chronic pelvic pain syndrome remains unclear. Further research is warranted to examine the mechanisms by which acupuncture therapy may improve clinical symptoms in patients with chronic prostatitis/chronic pain syndrome. The patient's diagnosis of pudendal neuralgia would not necessitate use of dry needling given that no specific trigger point involvement was identified by physical examination. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is board certified in acupuncture 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone HCL in three various dosages. The Centers for Disease Control and Prevention (CDC) guidelines on opioid prescribing suggest comprehensive steps at all stages of opioid initiation, monitoring, continuation, and discontinuation. The CDC specifically suggests that every three months if the 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. Within the documentation available for review, the records support the medical necessity of the oxycodone HCL tablets. This medication was a quantity consistent with the providers documented treatment plan. The provider evaluated the patient and determined that the patient could be switched to oral oxycodone tablets in conjunction with a trial of Hysingla. Therefore, the oxycodone HCL tablets were medically necessary for treatment of this patient. However, there is a lack of documentation to support use of oxycodone liquid. The patient had documentation of previous and upcoming dental work, but an update on her status with regard to the ability to swallow pills was not provided for review. In addition, the provider indicated in the progress notes that the plan was to change from liquid oxycodone to the tablet formulation. Thus, the oxycodone HCL liquid was not medically necessary. Further, there is a lack of support in the records for oxycodone HCL in higher dose. The records include a pharmacy benefit prescription history that the patient has been on oxycodone, and the quantity dispensed each month is slowly reduced. However, the records do not include urine drug testing results, functional improvement, and pain reduction to warrant this medication. In addition, opioid risk stratification is not evident in the records. Moreover, querying of the CURES database was not reported beyond the initial timeframe. This monitoring is required in an ongoing basis. Therefore, the oxycodone HCL tablets were not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the medication at issue was 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 physical medicine and rehabilitation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Uptravi. The submitted documentation supports the medical necessity of the requested medication. This patient has been diagnosed with WHO group 1 pulmonary hypertension. Uptravi is a prostacyclin receptor agonist which has been approved by the U.S. Food and Drug Administration for the treatment of patients with WHO group 1 pulmonary artery hypertension to delay disease progression and reduce the risk of hospitalization. The Health Plan has denied Uptravi and noted that the patient has not tried an endothelial receptor antagonist. The medical literature does not indicate that an endothelial receptor antagonist is indicated prior to pursuing treatment with Uptravi. There is sufficient support for the requested medication in this clinical setting. Therefore, Uptravi is medically necessary for the 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 internal medicine with sub-specialty certification in pulmonary 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 60-year old male who was diagnosed with coronary artery disease. He also has a history of chronic obstructive pulmonary disease, diabetes, hyperlipidemia, tobacco use, laryngeal cancer, and thyroid cancer. Findings:  The physician reviewer found that a Persantine nuclear stress test revealed no evidence of myocardial ischemia. In a letter, the provider noted that the patient underwent percutaneous transluminal coronary angioplasty and stenting to the left anterior descending artery in 2013. The patient endorsed sharp and stabbing chest pain not consistently relieved with nitroglycerin. There was no documentation the patient had been treated with a calcium channel blocker or long-acting nitrate. The patient has requested authorization and coverage for ranolazine. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether ranolazine is medically necessary for the treatment of the patients medical condition. Beta blockers should be prescribed as initial therapy for relief of symptoms in patients with stable ischemic heart disease (SIHD). Calcium channel blockers or long-acting nitrates should be prescribed for relief of symptoms when beta blockers are contraindicated or cause unacceptable side effects in patients with SIHD. Per the 2012 article by Fihn and colleagues, calcium channel blockers or long-acting nitrates, in combination with beta blockers, should be prescribed for relief of symptoms when initial treatment with beta blockers is unsuccessful in patients with SIHD. Although this patient has been diagnosed with coronary artery disease, his chest discomfort symptoms do not present as anginal in nature. There is no evidence of ischemia on stress testing, indicating that his symptoms are non-anginal. There is no documented angina or coronary ischemia. Furthermore, there is no documented trial or intolerance to other more standard anti-anginal medications, such as calcium channel blockers and long-acting nitrates. The medical evidence does not support the requested medication in this clinical setting. Therefore, ranolazine is not medically necessary for the treatment of this patient.   Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for bilateral hyaluronan injections for primary osteoarthritis of both knees. Her physician recommended Synvisc shots to relieve the pain. She reports having had a significant benefit in terms of pain relief from these injections in the past. The literature summarizing hyaluronic acid injections is well documented.  In general, the use of hyaluronic acid is not supported, since most studies indicate it does not show superiority over other treatments, including placebo, which has no therapeutic effect. The evidence is strong, based on multiple studies with consistent findings that do not recommend the use of hyaluronic acid. In a thorough review of the literature, although there is often a small statistical improvement, meta-analyses of pain, function, and stiffness subscales scores found none of the improvements met the minimum clinically important improvement thresholds.  Final Result: Findings: the physician reviewer found that 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 orthopedics and sports 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.