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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for skilled acute rehabilitation facility services. Findings:  The physician reviewer found that Acute tetraplegia requires complex, individualized rehabilitation to optimize function and maximize health outcomes (Hagen, E.; Nas, K., et al.; Chay, W., and Kirshblum, S.). Even if severe motor weakness precludes the realistic pursuit of full independence with self-care and functional ambulation, there are a number of pragmatic, realistic, appropriate, and warranted functional/therapeutic goals in this clinical setting, including tolerating time out of bed and sitting, dynamic sitting activities, slide board transfers, improving upper body self-care with adaptive equipment, improving skills and independence using a power mobility device, learning to mitigate risk of complications (e.g., autonomic dysreflexia, urinary tract infections, and skin breakdown), and learning to direct care (for future caregivers).In this case, the patient has acute C6 level complete tetraplegia due to trauma as a passenger of a motor vehicle that rolled over. Records reflect that the patient has been making functional progress at the acute inpatient rehabilitation hospital, including in the areas of eating, oral hygiene, grooming, bathing, and upper body dressing. He has been using a power mobility device more independently. These are all appropriate functional issues to continue to address and pursue with skilled rehabilitation services. The patient has not functionally plateaued and further gains are expected. Accordingly, the requested skilled acute rehabilitation facility services were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrogel spacers (CPT 55874). Findings:  The physician reviewer found that this patients treatment plan for prostate cancer includes proton beam radiation therapy with use of hydrogel spacers. The current studies demonstrating the safety and efficacy of hydrogel spacers have not included patients treated with proton beam radiation. Hamstra and colleagues found that the benefits of hydrogel spacer use in reducing the rectal dose increased with a longer follow-up period, providing stronger evidence for the benefit of hydrogel spacer use in prostate radiation therapy. Despite the support for use of the hydrogel spacers with photon beam therapy, there is a paucity of data demonstrating improved patient health outcomes with proton beam therapy. The use of hydrogel spacers in combination with proton beam radiation therapy is not supported by expert guidelines or high quality clinical trials. Therefore, the requested hydrogel spacers (CPT 55874) are 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 hydrogel spacers (CPT 55874) are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT).Findings:  Three of the three physician reviewers found the requested IORT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. While Correa and colleagues note equivalent outcomes in patients who undergo standard radiation therapy and IORT, this patient would fall into the cautionary group for the use of IORT based on her age. IORT is not recommended in patients who fall into the cautionary group. Likewise, the American Society of Breast Surgeons recommends partial breast radiation in patients older than age 45. Therefore, given this patients age, IORT is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service 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 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

Findings:  The physician reviewer found that An enrollee has requested reimbursement for laboratory testing (4K prostate score). The records provided for review document that this patient presented with a history of rising prostate specific antigen (PSA) and a family history of prostate cancer in his father, and a low free PSA level. The patient underwent evaluation with 4Kscore testing. Given the patients rising PSA value, family history, and low free PSA level, a biopsy would have been recommended for further evaluation of this patients condition. Moreover, the current peer-reviewed medical literature does not support routine use of the 4Kscore test in the evaluation of patients in this clinical scenario. Saltman and colleagues concluded that more research is needed to determine the novel biomarker testing such as 4Kscore in the evaluation and treatment of patients with prostate cancer. Therefore, the laboratory testing (4K prostate score) was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the laboratory testing (4K prostate score) was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for custom fabricated oral appliance. The records provided for review document that this patient has a history of symptomatic obstructive sleep apnea (OSA). The patient is noted to have mild-to-moderate OSA given her sleep study results revealing an apnea/hypopnea index (AHI) of 8.1 events per hour and a respiratory disturbance index (RDI) of 9.9 events per hour. The patients provider has recommended treatment with an oral appliance. The U.S. Food and Drug Administration (FDA) has approved oral mandibular advancement devices for the treatment of patients with mild-to-moderate OSA. In addition, the current medical literature supports the use of an oral mandibular advancement device for use in the treatment of this patients mild-to-moderate OSA in order to prevent potential sequelae of her condition. Given these findings, the requested custom fabricated oral appliance is medically necessary for 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 subspecialty certification in sleep 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 patient has requested authorization and coverage for Dupixent solution pen injection 300 mg/2 mL. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. A recent consensus article of atopic dermatitis experts defined moderate-severe atopic dermatitis as greater than 10% body surface area (BSA) involvement and/or involvement of highly visible areas or those important for function, and significantly impaired quality of life (Boguniewicz, et al.). The records provided for review document that this patient has significant itching from his atopic dermatitis on his face. The patients symptoms were improved with betamethasone, which is not a long-term treatment option due to the risk of ocular toxicity. The patients condition was not well controlled with topical pimecrolimus. The patients symptoms were also controlled when the patient attempted treatment with Dupixent. The location of the patients disease involvement and symptoms meets the current criteria for moderate-to-severe disease. In addition, Dupixent has the highest-quality trial evidence for safety and efficacy in atopic dermatitis (Siegels, et al.). Moreover, immunosuppressant treatment with medications such as methotrexate, mycophenolate, azathioprine, and cyclosporine may increase the patients risk of developing an infection, especially given the COVID-19 pandemic. All told, the requested Dupixent solution pen injection 300 mg/2 mL is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transfer to a higher level of care (from a skilled nursing facility (SNF) services to inpatient hospital services). The available records document that this patient has multiple chronic medical problems and ongoing mobility challenges. The provider reported that the patient has been chronically noncompliant with her care. There is a lack of evidence that the patient has any active, acute medical issues that could not be addressed in an ambulatory setting and requires acute hospitalization for further evaluation or treatment such as acute infection, congestive heart failure, exacerbation of chronic obstructive pulmonary disease, a fall-related acute injury, or alteration in consciousness. The available records do not indicate that the patient has any acute functional deficits requiring intensive multidisciplinary rehabilitation services consistent with the acute inpatient rehabilitation setting of care. Therefore, the requested transfer to a higher level of care (from a SNF services to inpatient hospital services) 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for septoplasty and turbinate resection. In 2019, van Egmond and colleagues published a randomized controlled clinical trial of surgery versus non-surgical therapy for the treatment of nasal obstruction in adults with a deviated nasal septum. The authors included 203 patients and compared septoplasty with or without turbinoplasty and non-surgical management ranging from watchful waiting to topical corticosteroids, saline nasal spray, and other medications. The authors found that septoplasty was more effective than non-surgical management in improving objective outcomes and subjective measures at 24-month follow-up. This study provides high-quality peer-reviewed evidence to support the use of septoplasty with or without turbinate reduction for the management of this patients symptoms. Based on this patients complaints and the providers assessment, the requested septoplasty and turbinate resection are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 a Synvisc injection in the left and the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections received in three years prior. The patient has radiographic evidence of osteoarthritis with joint space narrowing and tricompartmental osteophytosis in the right knee with a history of ACL reconstruction. The patients left knee pain is likely due to chondramalacia due to age. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Synvisc injection in the left and the right knee 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for opium tincture 1% (equivalent to morphine 10 mg/mL) 7 mL every six hours.The submitted documentation supports the medical necessity of the requested medication. The treatment options for short bowel syndrome are limited, and the patient has already failed other options. Current medical literature supports the use of opium tincture for the treatment of short bowel syndrome. Parrish and DiBaise noted, Tincture of opium should be considered in patients with short bowel syndrome who have failed therapy with loperamide or diphenoxylate. American Society of Colon and Rectal Surgeons guidelines state that opioids result in decreased intestinal motility, decreased intestinal secretion, and increased absorption. Opiates are recommended as safe and effective for the treatment of chronic diarrhea. Tincture of opium has been effective in this patients case. Therefore, opium tincture 1% (equivalent to morphine 10 mg/mL) 7 mL every six hours 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left heart cardiac catheterization and coronary angiography. Coronary microvascular dysfunction (CMD) is a broad term that, in the absence of obstructive coronary disease, includes any pathology that may disrupt the microvasculature, including endothelial dysfunction, coronary spasm, inflammation, and atherosclerosis. There are a number of imaging methods available to measure myocardial blood flow in the setting of microvascular dysfunction. The American College of Cardiology (ACC) and American Heart Association (AHA) guideline for the evaluation and diagnosis of chest pain note that the use of invasive coronary function testing is reasonable in patients with suspected ischemia with non-obstructive coronary disease (INOCA) to improve the diagnosis of CMD and to enhance risk stratification when there is evidence of persistent chest pain, nonobstructive coronary artery disease, and myocardial ischemia. These components did appear to be present in this patient. In this clinical setting, cardiac catheterization with coronary function testing for evaluation of suspected CMD or INOCA is medically indicated. Therefore, left heart cardiac catheterization and coronary angiography are medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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 sub-specialty 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: An enrollee has requested authorization and coverage for Privigen 10% infusion (HCPCS J1459), 160 units every four weeks.Treatment of severe dermatomyositis must be individualized based on the clinical findings, presentation, and lab values. In particular, severe cutaneous dermatomyositis is not as responsive to prednisone but can be responsive to other systemic agents including methotrexate and IVIG (Cobos, G., et al.). Cobos and colleagues mention that IVIG is quickly started for patients with severe skin disease, and it can help to discontinue immunosuppressive agents such as prednisone or methotrexate.In this case, the patient has documented findings that are consistent with severe skin disease. The patient is currently on methotrexate and prednisone with some improvement. The provider has prescribed IVIG based on the severe cutaneous findings (muscle findings by MRI were found later and prednisone started in response). As methotrexate is immunosuppressive, given the COVID-19 pandemic, it has been associated with increased hospitalization if a patient is infected with COVID-19. Given the prevalence of the omicron variant and breakthrough infections despite vaccination, the provider has noted that it would be prudent to try to decrease methotrexate and prednisone dosing as rapidly as possible as it would be best to avoid agents that increase COVID-19 morbidity. Under these circumstances, the requested medication Privigen 10% infusion (HCPCS J1459), 160 units every four weeks, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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.