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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral iliac vein angiogram, left renal vein angiogram, IVUS, and possible angioplasty of any scarring in the iliac veins. Basile and colleagues report that pelvic congestion syndrome (PCS) is often an underdiagnosed cause of chronic pelvic pain that may occur either alone or in combination with vulvar varicosities and/or lower extremity venous insufficiency. In this case, the patient has undergone extensive workups including endoscopies and diagnostic laparoscopy. The records document symptoms that may represent a component of pelvic congestion or renal vein stenosis. Given that the patient has  exhausted other reasonable avenues, the requested services are medically indicated. Therefore, bilateral iliac vein angiogram, left renal vein angiogram, IVUS, and possible angioplasty of any scarring in the iliac veins are medically necessary for the evaluation of 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 general surgery and in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SpaceOAR Hydrogel (CPT 55874  hydrogel spacer). Findings:  The physician reviewer found that review of the available documentation, this patient is noted to have a history of prostate cancer. As part of his treatment regimen, the patients provider has recommended use of hydrogel spacers to decrease the toxicity to the rectum while the patient receives proton beam radiation therapy. As noted in the medical literature, hydrogel spacers can be utilized during radiation treatment of the prostate to increase the space between the rectum and prostate and decrease the amount of radiation that is delivered to the rectum (Hamstra, et al.). In a randomized phase 3 study in patients undergoing radiation for prostate cancer, the risk of late adverse events grade 2 or higher, declined from 5.7% to 0% in the control versus hydrogel spacer group. The spacer group also had a significant reduction in bowel quality of life decline. The National Comprehensive Cancer Network (NCCN) guidelines also endorse the use of hydrogel spacers in patients undergoing radiotherapy for prostate cancer. Given this support, the requested SpaceOAR Hydrogel (CPT 55874  hydrogel spacer) 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 SpaceOAR Hydrogel (CPT 55874  hydrogel spacer) 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for speech generating device, Accent 800 with WordPower (CPT E2510), Rehadapt Custom Mount (CPT E2512), and Symbol Stix, QRM Plate, and Spec Switch Accessories (CPT E2599). Per the American Speech-Language-Hearing Association (ASHA) recommendations, eligibility for communication services and supports should be based on individual communication needs. Communication services and supports should be evaluated, planned, and provided by an interdisciplinary team with expertise in communication and language form, content, and function, as well as in augmentative and alternative communication (AAC). Morin and colleagues reviewed 18 multiple-baseline or multiple-probe experiments across 17 studies indicate that using high-tech AAC to teach social-communication skills to individuals with autism spectrum disorder or intellectual disabilities and complex communication needs can be considered an evidence-based practice. The records provided for review suggest that this patient with Lennox-Gastaut syndrome, developmental delays, epilepsy, and cortical visual impairment is not expected to develop oral language. The patient underwent a thorough evaluation by a provider who specializes in the evaluation of young patients for AAC devices. The provider noted that less technologically complex devices are inadequate for this patients communication needs. The patient has cortical visual impairment, which limits his options to devices that incorporate auditory scanning. The speech generating device, Accent 800 with WordPower and related accessories, is appropriate to enable the patient to effectively communicate wants and needs. The patient has demonstrated the ability to use the device and ongoing speech therapy using the device is planned. For these reasons, the requested speech generating device, Accent 800 with WordPower (CPT E2510), Rehadapt Custom Mount (CPT E2512), and Symbol Stix, QRM Plate, and Spec Switch Accessories (CPT E2599) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for computed tomography (CT) of the heart (CPT 75571). Based on the current guidelines from the American College of Cardiology (ACC), a coronary artery calcium score is reasonable for the purpose of determining whether a patient should start statin therapy for a borderline elevated low density lipoprotein (LDL) cholesterol level (Blankstein). However, there is a lack of support for using serial coronary artery calcium scoring to assist in the adjustment of statin dosing. This patients records do not include documentation of low density lipoprotein (LDL) cholesterol results either before or following statin initiation. As noted in the medical literature and guidelines, the chief purpose of the coronary artery calcium score is to aid in decision making as applied to statin therapy initiation. This patient was noted to have been on a statin at the time of CT scan of the heart. Further coronary artery calcium score tests have not been subjected to outcomes data in patients already on statins. For these reasons, the CT scan of the heart (CPT 75571) was not medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 internal medicine with subspecialty certification in cardiology 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 Humira Pen 40 mg/0.4 ml, every seven days. The submitted documentation supports the medical necessity of the requested medication regimen in this clinical setting. Anti-tumor necrosis factor (TNF) medications such as Humira are recommended by current guidelines for Crohns disease in patients with moderate to severe disease. The use of Humira 40 mg more frequently than every 14 days can be supported to prevent disease complications. Sandborn and colleagues reported that the remission rate with weekly dosing was 46.9% versus 22.5% when dosing every other week. Additionally, American College of Gastroenterology guidelines for the treatment of Crohns disease state, Those with continued symptoms shouldhave their medication dose adjusted in order to attempt to optimize therapy. In this case, the patient had active disease (requiring corticosteroids) on Humira 40 mg every 14 days. Therefore, the use of Humira 40 mg every 14 days, or a discontinuation of Humira (even if another alternative is immediately attempted), could result in complications of disease activity, such as disease flare, fistula, need for surgery, hospitalization, or recurrent abscess. Therefore, Humira Pen 40 mg/0.4 ml, every seven days is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 (1) Xeljanz extended release 11 mg tablets and (2) Humira injector pen 40 mg/0.4 mL subcutaneous kit. Findings:  The physician reviewer found that  there are few therapies for the treatment of moderate-to-severe hidradenitis suppurativa (HS), Humira has been studied and approved by the U.S. Food and Drug Administration (FDA) for this indication. While the FDA recommended dosage is 40 mg weekly, Bouguen and colleagues note that adalimumab 80 mg weekly is well-tolerated and effective in the treatment of Crohns disease, indicating that 80 mg weekly is a safe dosage. Current medical literature includes several recently completed and ongoing clinical trials on the use of Janus kinase (JAK) inhibition for the treatment of HS. Alavi and colleagues report that JAK  inhibitors have been well tolerated, with observable response, and that the safety and efficacy findings from these studies support JAK1 inhibition in HS. Savage and colleagues report that the JAK inhibitor, tofacitinib, suppresses inflammatory cytokines implicated in HS pathogenesis, and may benefit patients with recalcitrant HS. In this case, the patient has severe HS, Hurley stage III, with significant pain affecting her quality of life. She has tried infliximab, Humira, oral antibiotics, topical clindamycin, and oral contraceptives. The records noted that her disease was not controlled on Humira 80 mg weekly monotherapy. Her disease has been controlled on the current medication regimen of Humira 80 mg weekly and Xeljanz 11 mg extended release daily for the past seven months. Given this patients response to her current regimen and the known action of these two agents and the biology of HS, the requested medication regimen is medically indicated. Therefore, (1) Xeljanz extended release 11 mg tablets and (2) Humira injector pen 40 mg/0.4 mL subcutaneous kit are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 dermatlogy 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 Durolane injection in both knees. Findings: 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 intra-articular injections of Durolane into both knees. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Durolane injection in both knees 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 28 fractions of proton beam therapy to a high dose of 70 Gy. There is a lack of support for the requested services in this clinical setting. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a recent multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer. The authors compared groups receiving hypofractionated proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. A position statement released by The American Society for Radiation Oncology (ASTRO) stated, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. ASTRO noted that the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity modulated radiation therapy technique. Therefore, 28 fractions of proton beam therapy to a high dose of 70 Gy is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in radiation oncology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Rasuvo 25 mg/0.5 mL injected weekly. For patients with uncontrolled rheumatoid arthritis symptoms despite taking oral methotrexate, the American College of Rheumatology (ACR) guideline for the treatment of rheumatoid arthritis recommends switching to subcutaneous methotrexate over the addition of or switching to alternative disease-modifying antirheumatic drugs (DMARDs). Senbel and colleagues report that changing from oral to subcutaneous route may improve adherence, control of rheumatoid arthritis, and quality of life even in patients with an unchanged methotrexate dose. When administered subcutaneously, the bioavailability and efficacy of methotrexate is improved as it bypasses the requirement for active gastrointestinal absorption of the drug as required when administered orally. In this case, the records indicate that the patient has failed to respond to oral methotrexate. The patient also reports a severe needle phobia and has been tolerating Rasuvo auto-injector pen therapy without an exacerbation of anxiety related to a needle phobia. In this clinical setting, given the patients failure to respond to oral methotrexate tablets, the requested medication is medically indicated. Therefore, Rasuvo 25 mg/0.5 mL injected weekly 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.
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 Xifaxan tablet 550 mg. The American Gastroenterological Association (AGA) reports that small intestinal bacterial overgrowth (SIBO) is commonly diagnosed among individuals presenting with a variety of gastrointestinal symptoms. The AGA further reports that management includes the administration of antibiotics, but notes that there is a limited database to guide the clinician in developing antibiotic strategies for SIBO, and that therapy remains, for the most part, empiric. The U.S. Food and Drug Administration (FDA) approves the use of Xifaxan for the treatment of irritable bowel syndrome with diarrhea predominance (IBS-D). Medical literatures note that rifaximin has also been found to resolve symptoms in patients with SIBO, concluding that rifaximin appears to be effective and safe for the treatment of SIBO. Medical literatures report that rifaximin alters methane production. While data on rifaximin for SIBO in children are more limited, in a review of literature, researchers state, Taken together, these results indicate that antibiotics are an effective means of treating SIBO in children and, although non-rifaximin antibiotics appear to produce greater resolution, the data is weaker for such medications and rifaximin has demonstrated safety in a greater number of participants and studies. In this case, while information on the choice of antibiotics for SIBO treatment is thin, given this patients age and the presence of methane on a lactulose breath test, the requested medication is indicated as the safest and most effective treatment option. Therefore, Xifaxan tablet 550 mg 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 pediatrics with sub-specialty certification in pediatric 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency.Findings: Three out of three physician reviewers found that the requested services are not likely to be more beneficial than any available standard treatment for the enrollee's medical condition.This patient presents with increased symptomatology and increased fibroid size despite treatment with medication and after previous excisional treatment. Radiofrequency ablation has been requested to treat the patients fibroids. The radiofrequency ablation (RFA) procedure was first described in American medical literature in 2002, and it was approved by the U.S. Food and Drug Administration (FDA) in 2012. According to medical literatures, 94% of women in their study reported satisfaction at 12 months. Their conclusion is that the procedure is well tolerated and provides symptom relief, short recovery time, and improved quality of life. The data seems promising and RFA may be superior to the Uterine Artery Embolization (UAE) which would be the closest alternative in this case. Five-year data for the UAE procedure shows a return of symptoms in 25 to 33% of women. According to American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin Number 228, Laparoscopic radiofrequency ablation can be considered as a minimally invasive treatment option for the management of symptomatic leiomyomas in patients who desire uterine preservation and are counseled about the limited available data on reproductive outcomes. While the requested radiofrequency ablation procedure may be equivalent to the patients other treatment options, long-term data is not available to deem it superior to all other therapies for fibroids. Therefore, the requested transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency is not likely to be more beneficial than any available standard treatment for the patient's medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any available standard treatment for the patient's medical condition. 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. All three reviewers are experts in the treatment of the enrollees medical condition and are knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.