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 an Intracept procedure (procedure code 22899) and destruction of intraosseous basivertebral nerves (procedure codes C9752 and C9753). Truumees and colleagues reported significant improvement in pain and function in patients with vertebrogenic-related chronic low back pain treated with minimally invasive radio frequency ablation of the basivertebral nerve. Markman and colleagues noted an association between functional benefit from basivertebral nerve ablation and reduced opioid use. Fischgrund and colleagues found that patients with chronic low back pain treated with radiofrequency ablation of the basivertebral nerve in a randomized controlled trial exhibited sustained clinical benefits in the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) and maintained high responder rates at two years following treatment. The authors concluded that basivertebral nerve ablation appeared to be a durable, minimally invasive treatment for the relief of chronic low back pain. In this case, the requested service is an outpatient procedure that would allow to patient to avoid more invasive alternatives such as fusion and or artificial disc replacement while maintaining the structural integrity of the spine. Therefore, the requested Intracept procedure (procedure code 22899) and destruction of intraosseous basivertebral nerves (procedure codes C9752 and C9753) are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Intracept procedure (procedure code 22899) and destruction of intraosseous basivertebral nerves (procedure codes C9752 and C9753) 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 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 orthopedic surgery 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 facial feminization surgeries to include the following specific surgeries: CPT 21139 (reduction forehead), CPT 14041 (adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet), CPT 67900 (repair (brow ptosis, blepharoptosis, lid retraction, ectropion, entropion), procedures of the eyelids), CPT 30420 (rhinoplasty, primary), CPT 21209 (osteoplasty, facial bones), and CPT 64611 (somatic nerve).Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. The World Professional Association for Transgender Healths (WPATH) Position Statement on Medical Necessity of Treatment noted that non-genital surgical procedures, including facial feminization surgery, are often of greater practical significance in the patients daily life than reconstruction of the genitals. WPATH noted, These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. In this case, the patient has been diagnosed with gender dysphoria and has symptoms caused by her facial features. Therefore, the requested facial feminization surgeries: CPT 21139 (reduction forehead), CPT 14041 (adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet), CPT 67900 (repair (brow ptosis, blepharoptosis, lid retraction, ectropion, entropion), procedures of the eyelids), CPT 30420 (rhinoplasty, primary), CPT 21209 (osteoplasty, facial bones), and CPT 64611 (somatic nerve), are medically necessary for the treatment of the 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 psychiatry with expertise in transgender 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 patients parent has requested authorization and coverage for pediatric neurology and/or hematology services at a pediatric tertiary care center. This patients records support a diagnosis of neurofibromatosis 1 (NF1). NF1 is a genetic disorder in which the NF1 gene produces neurofibromin that are unable to function as tumor suppressors, which increases the likelihood of a patient developing neoplasms in the nervous system. This patient has demonstrated increases in neurocutaneous stigmata as well as findings suggestive of changes in myelin. Thus, it is appropriate for the patient to undergo follow-up with a pediatric neurologist at a pediatric tertiary care center with interval neuroimaging based on the providers treatment plan. Although the pediatric neurologist may recommend the services of a hematologist, the medical records provided for review do not support a current indication for hematology services at a pediatric tertiary care center. Therefore, the requested pediatric neurology services at a pediatric tertiary care center are medically necessary for this patient, while the requested hematology services at a pediatric tertiary care center are not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services 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 neurology with special qualification in child neurology 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 reimbursement for SpaceOAR System (CPT 55874). This patient has a history of stage T1 Gleason score 4+4=8 adenocarcinoma of the prostate. The patient underwent treatment with Lupron as well as prostate seed implantation along with external beam radiation therapy with placement of SpaceOAR perirectal spacers. One important consideration during prostate radiation is rectal toxicity due to exposure of the adjacent rectum to radiation. A mechanism of dealing with this issue is to create a space between the prostate and rectum, so that the rectum is out of the radiation treatment field and receives less radiation. Karsh and colleagues reported on a phase 3 study evaluating the safety and effectiveness of the SpaceOAR perirectal spacer in the treatment of prostate cancer. The authors found that the patients who underwent radiation therapy with SpaceOAR placement experienced reduced rectal radiation and rectal toxicity as well as improved bowel quality of life. The National Comprehensive Cancer Network (NCCN) recently endorsed the use of SpaceOAR perirectal spacers and noted that their use can improve sparing of the adjacent rectum in patients undergoing radiation therapy for prostate cancer. Based on the results of the positive phase 3 study and the endorsement by the NCCN, the placement of SpaceOAR System (CPT 55874) was 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 placement of SpaceOAR System (CPT 55874) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Entresto. Findings:  The physician reviewer found that  (FDA) has approved Entresto for the treatment of patients with heart failure with preserved or mildly depressed ejection fraction. The FDA label also indicates that left ventricular ejection fraction is a variable measure, and clinical judgment should be used in deciding whom to treat. In the study by Solomon and colleagues, the subgroup of patients with an ejection fraction less than 57% showed significant benefit with Entresto treatment. This led the FDA to recently approve Entresto in this patient subgroup. In this case, the patient has a possible familial dilated cardiomyopathy. Her LV is dilated, and her EF is mildly depressed. She is being started on medical therapy as part of a genetic cardiomyopathy evaluation. Although minimal symptoms are present, she is at risk for more severe symptomatic congestive heart failure. Based on prior published data, treatment can affect outcomes, even in the absence of clinical symptoms. Thus, Entresto is medically necessary for the treatment of the patients medical condition.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 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 patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine. Findings:  The physician reviewer found that MRI of the cervical spine may be appropriate for the evaluation of patients with prior cervical spine surgery, new or increasing non-traumatic cervical or neck pain, or cervical radiculopathy. Current evidence-based medical criteria for cervical spine MRI generally includes emergence of physiologic evidence of tissue insult or neurologic dysfunction, progressive neurologic symptoms, failure of conservative treatment, or clarification of anatomy prior to an invasive procedure. This patient presents with cervicalgia, paresthesia of skin, pain in upper arm, and abdominal pain. Physical examination revealed complaints of chronic joint pain throughout her body. The pain is worse in her posterior neck with burning, numbness, and tingling sensations that radiate from her neck down to both arms and hands. She reports a similar burning sensation in her bilateral armpits. There is bilateral flank pain that radiates to the front of her abdomen. The provider noted that physical examination of the neck revealed positive posterior cervical spine tenderness to palpation, including along the paraspinal muscle in this area. There were no motor or sensory deficits noted. Detailed documentation is not evident regarding objective clinical findings of myotomal weakness, reflex loss, or sensory deficits to support an indication for further evaluation with MRI. In addition, trial and failure of recent, reasonable and comprehensive less invasive conservative care measures is not documented in the records provided for review. For these reasons, the requested MRI of the cervical spine is not medically necessary.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: An enrollee has requested authorization and coverage for botulinum toxin injections. Findings:  The physician reviewer found that The American Headache Society (AHS) recommends preventive treatment when attacks significantly interfere with daily routines despite acute treatment; when a patient has four or more attacks per month; or when a patient has contraindication to, failure, or overuse of acute treatment. OnabotulinumtoxinA (Botox) has been approved for the treatment of chronic migraine. The lack of need for slow dose escalation, the rapid onset of therapeutic benefits, and the favorable tolerability profiles are advantages that injectable therapies have in common. In 2016, the American Academy of Neurology (AAN) updated its 2008 guidelines on using botulinum neurotoxin for brain disorders. Botulinum toxin A is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. Frampton and Silberstein performed a review of the current evidence of onabotulinumtoxinA in the prevention of chronic migraine. The authors reported, The totality of evidence from clinical trials and real-world studies indicates that onabotulinumtoxinA is an effective and generally well-tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. In this case, the patient has a history of chronic migraines and has not responded to multiple oral preventative medications. Based on the AHS statement, AAN guideline, and study noted above, the patient is a candidate for prophylactic treatment with botulinum toxin therapy. Moreover, the patient has experienced clinical improvement with botulinum toxin therapy. Therefore, the requested botulinum toxin injections are medically necessary for the treatment of the 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 neurology 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 Revlimid (lenalidomide) 25 mg capsule, in a cycle of 1 capsule by mouth daily for 21 days, then off for 7 days, for a six month period. Findings:  The physician reviewer found that treatment of multiple myeloma support the use of Revlimid for high risk patients for up to two years based on improved progression free survival and decreased end organ damage. In this case, the patient has a diagnosis of smoldering multiple myeloma that is high risk based on bone marrow findings. He has so far received five cycles of Revlimid and remains on close observation. In this clinical setting, the requested medication is medically indicated. Therefore, Revlimid (lenalidomide) 25 mg capsule, in a cycle of 1 capsule by mouth daily for 21 days, then off for 7 days, for a six-month period 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 internal medicine with sub-specialty certifications in medical oncology and hematology 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 the RT300 Functional Electrical Stimulation (FES) therapy system. There is a lack of evidence in current medical literature demonstrating that exposure to passive exercise, such as would be provided by the requested device, improves function or health outcomes in a clinically significant manner for neurological conditions, including complete traumatic paraplegia. Researchers report that while treatment options using neurostimulation to enable or enhance intense training appear promising, regaining lost motor function remains challenging, and characterizing long-term benefits and side-effects in clinical trials also remains crucial. Medical literature noted that in a study of 14 patients with recent spinal cord injury, there were no clear effects of FES cycling on increasing urine output, decreasing lower limb swelling and spasticity. Researchers note that more rigorous research involving a greater number of participants is needed before determining the efficacy of FES cycling as an intervention for youth with spinal cord injury. Researchers note that patients with traumatic spinal cord injury benefit from active exercise using volitionally intact muscles, and the general encouragement of active participation in educational, social, recreational, avocational and vocational activities. Given that current medical literature does reflect that the use of the requested device would improve cardiovascular health, pulmonary health or other health parameters in any clinically significant manner, the requested device is not medically indicated. Therefore, the RT300 FES therapy system 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 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 LINX procedure (CPT 43284). The records provided for review document that this patient has a history of gastroesophageal reflux disease (GERD) with symptoms of voice hoarseness and sore throat, which interfere with his ability to sing as his occupation. The patients provider has recommended the LINX procedure. However, the LINX procedure is not considered the standard of care for patients with GERD due to the lack of rigorous evidence-based literature comparing existing therapeutic interventions for safety, efficacy, and durability over the long-term. Scientific evidence has not been established via well-designed controlled studies with adequate follow-up demonstrating the safety and efficacy of the LINX procedure. Direct comparative studies between surgical interventions are needed to better assess the long-term safety and efficacy of the LINX procedure against other surgical anti-reflux interventions, such as the Nissen fundoplication (Sheu and Rattner). Adverse events including erosion through the esophagus have been reported (Bauer, et al.). Based on current evidence and medical literature, the requested LINX procedure (CPT 43284) 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 LINX procedure (CPT 43284) 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 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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 30 sessions of 30-minute hyperbaric oxygen treatment.About 15% to 25% of people with diabetes will develop a foot ulcer. Researchers state that wound infections are a serious potential complication of diabetes and are a known predictor of poor wound healing and amputation. Researchers noted that hyperbaric oxygen therapy  is a potential therapeutic option for diabetic foot ulcers. According to medical literature, studies have shown that hyperbaric oxygen may be effective after 2 to 10 weeks at reducing the risk of major amputations in patients with severely infected diabetic foot ulcers. In this case, the patients foot wound has not healed properly, and he has experienced infections. Additionally, MRI records show mild edema in the cuboid. Therefore, 30 sessions of 30-minute hyperbaric oxygen treatment are medically necessary for the treatment of the 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 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.