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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Zoll LifeVest wearable cardioverter defibrillator. Findings:  The physician reviewer found that The documented high-risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter defibrillators. Current data from multiple trials support the use of a wearable cardioverter defibrillator, such as the Zoll LifeVest, following an initial diagnosis of severe left ventricular dysfunction with an ejection fraction of 35% or less (Kutyifa, et al.; Klein, et al.; Epstein, et al.). The placement of a LifeVest is planned for 90 days after initial diagnosis of severe left ventricular dysfunction. This timeframe allows for possible improvement in the patients ejection fraction while on guideline-directed medical therapy, which could avoid the need for an implantable cardioverter defibrillator. According to the records, this patients ejection fraction was 20-25%. The provider noted that the patients ejection fraction improved over time and the LifeVest was appropriately removed within the 90-day window, as per accepted guidelines and in accordance with the standard of care. For these reasons, the Zoll LifeVest wearable cardioverter defibrillator was 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 Zoll LifeVest wearable cardioverter defibrillator 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 internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for percutaneous vertebral augmentation units: 1 Findings:  The physician reviewer found that  Health Quality Ontario reports that cancers that metastasize to the spine and primary cancers such as multiple myeloma can result in vertebral compression fractures or instability and that conservative strategies, including bed rest, bracing, and analgesic use, can be ineffective, resulting in continued pain and progressive functional disability limiting mobility and self-care. The authors note that both vertebroplasty and kyphoplasty significantly and rapidly reduced pain intensity in cancer patients with vertebral compression fractures, significantly decreased the need for opioid pain medication, and resulted in functional improvement areas involved. Srensen and colleagues report that percutaneous vertebroplasty and kyphoplasty are safe and effective palliative procedures for painful vertebral compression fractures due to malignancy. Given the current medical literature, the requested services are medically indicated. Therefore, percutaneous vertebral augmentation units: 1  is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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 brand name medication Norco 10-325 tablet. The U.S. Food and Drug Administration (FDA) asserted that, a generic drug is a medication created to be the same as an already marketed brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use. These similarities help to demonstrate bioequivalence, which means that a generic medicine works in the same way and provides the same clinical benefit as its brand-name version. Per the Centers for Disease Control and Prevention (CDC) guidelines, Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids . In this case, the patient has chronic pain that has reportedly been treated with generic hydrocodone, and brand name Norco in the past. The patient indicated that the brand name formulation of Norco did not cause the somnolence, nausea, and constipation that she experienced with the generic hydrocodone formulation. She reports that she has used more medication than was prescribed to receive the same analgesic benefit. The reported side effects of nausea, constipation, and somnolence are common side effects of all opioid medications and are not unique to generic formulations of Norco. Based on the medical records for review and the FDA statement on generic drug bioequivalence, the requested brand name medication Norco 10-325 tablet is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested brand name 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiotherapy. There are inadequate clinical data to determine that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues evaluated the comparative effectiveness of intensity modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy in the treatment of prostate cancer. The authors found that in the comparison between IMRT and proton therapy, IMRT patients experienced a lower rate of gastrointestinal morbidity and there were no other significant differences regarding toxicities observed. Yu and colleagues performed an analysis of early toxicity comparing 421 patients treated for prostate cancer with proton therapy and 842 patients treated with IMRT. The authors concluded that there was a statistically significant decrease in genitourinary toxicity at six months with proton therapy, but this difference disappeared by one year, and there were no other significant differences in toxicity between the two techniques. The current American Society of Radiation Oncology (ASTRO) has taken the position that, the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network (NCCN) guidelines endorse the position statement by ASTRO given the lack of evidence showing a benefit with proton therapy over standard treatment with photons and IMRT technique. This patients provider included a dose comparison, but this is insufficient support for the use of proton therapy as the rectal doses with photons can be further reduced and optimized using a variety of standard techniques with IMRT. For these reasons, the requested proton beam radiotherapy 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two (2) additional acupuncture treatments.Peer reviewed literature recommends an initial trial of five to six acupuncture appointments in combination with a conditioning program of aerobic and strengthening exercises to stimulate self-reliance. Future acupuncture appointments should be tied to improvements in objective measures to justify an additional 6 sessions, for a total of 12 sessions. Additional treatments should only occur based on progressively greater, incremental objective gains. In addition, passive care (acupuncture) should be combined with active care (conditioning-aerobic-stretching exercise program) to stimulate self-care and avoid medical dependency. Indications for care discontinuation would include resolution, intolerance, lack of measurable improvements, or non-compliance including non-compliance with aerobic and strengthening exercises.In this case, the patient suffers from chronic, bilateral foot pain that has been treated with acupuncture. While the patient has reported that prior acupuncture care has been beneficial, no pre-acupuncture and post-acupuncture baselines were documented for comparison purposes. After an extensive number of prior acupuncture sessions were completed, the provider failed to document any measurable, progressive, significant, objective functional improvement (quantifiable response to treatment) obtained with previous acupuncture to support the reasonableness and necessity of the additional acupuncture requested. Because no recent physical examination has been documented, the patients deficits (motor-sensory-functional) are unknown, and the patients goals with the requested acupuncture are unclear. In addition, there is no clear documentation that indicates whether the patient is currently undergoing an independent exercise program (conditioning-aerobic-stretching exercise program based on patient's tolerance), which is essential to stimulate self-reliance and avoid acupuncture co-dependence. Therefore, the submitted documentation does not demonstrate a reduced need for medication or a measurable improvement in function or activities of daily living that is directly attributable to prior acupuncture. Under these circumstances, the requested two (2) additional acupuncture treatments are not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed acupuncturist, board certified in oriental 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for sublingual immunotherapy and/or food tolerance induction. This patient presents with food allergies and eczema. His parent has requested treatment in a tolerance induction program. Currently, the American Academy of Allergy Asthma and Immunology (AAAAI) does not recommend tolerance induction as a standard of care treatment for patients with food allergies due to the uncertainty whether the potential therapeutic benefits outweigh the risks of treatment (Nowak-Wegrzyn, et al.; Gernez and Nowak-Wegrzyn). Although some studies have reported positive outcomes, according to the AAAAI, the interventions and endpoints used in clinical trials have been too inconsistent to establish oral immunotherapy as superior to allergen avoidance. Furthermore, there is significant potential for adverse events including oropharyngeal, respiratory, and gastrointestinal side effects (Scurlock). Therefore, the requested sublingual immunotherapy and/or food tolerance induction is not 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 sublingual immunotherapy and/or food tolerance induction 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 reviewer 1 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology with subspecialty certification in pediatrics and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology 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: Upheld Decision of Health Plan

ature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ultrasound guided perirectal trigger point injections (CPT 99214, 20552, 20553, and 76942). Findings:  The physician reviewer found that treatment options for rectal pain syndromes and concluded that appropriate treatments included electrogalvanic stimulation, biofeedback training, muscle relaxants, digital massage of the levator ani muscles, and sitz baths. In one study, patients with chronic proctalgia received either electrical stimulation or digital massage of the levator ani and warm sitz baths or pelvic floor biofeedback plus psychological counseling. The analysis showed that 87% reported adequate relief of rectal pain after biofeedback. This improvement was maintained 12 months later.Hong and Ding reviewed current treatments for female pelvic floor dysfunction with regards to myofascial pelvic pain. Their review suggested that myofascial pelvic pain (MFPP) can be effectively treated with a variety of physical therapy techniques, such as manual therapy, biofeedback, relaxation training, electrical stimulation, and medication. Suppository medication with a muscle relaxant, nonsteroid anti-inflammatory drugs, and painkillers for 1 to 2 weeks were helpful for most patients in initial management. Subsequently, physical therapy carried by a well-trained physical therapist was also critical. However, no standardized or superior physical therapy protocol was reported. For refractory MFPP, intra-levator muscle Botox injections with a standard pudendal block kit can be considered.In this case, the patient reported unspecified rectal pain for 2 to 3 years. Provider notes do not indicate that a pelvic or rectal exam were performed. These notes also do not include diagnoses of myofascial pelvic floor pain or a recognized functional anorectal pain syndrome such as proctalgia fugax or levator ani syndrome. As noted above, the review by Rao discussed several treatment options for functional rectal pain syndromes, however, trigger point injections were not discussed or recommended. A more recent review by Hong from 2019 discussed treatment options for pelvic floor pain, and likewise, there was no discussion or recommendation for myofascial trigger point injections. Accordingly, the ultrasound guided perirectal trigger point injections (CPT 99214, 20552, 20553, and 76942) at issue were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty certification in pain 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Test. The DecisionDx-Melanoma test has shown some accuracy in determining risk for metastasis in melanomas. However, there is a paucity of data demonstrating that the results help direct treatment with a positive impact on long-term patient health outcomes. The DecisionDx-Melanoma test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Medical literatures reported that gene expression tests such as DecisionDx-Melanoma for patients with stage one or two melanoma have poor performance in predicting outcomes. Moreover, researchers noted that their assessment on DecisionDx-Melanoma testing does not show any benefit with regard to clinical utility. The standard of care in this patients clinical setting includes wide local excision and follow-up skin surveillance. Additional testing with the DecisionDx-Melanoma was not likely to impact the patients treatment planning pursuant to the recommendations in the current guidelines and medical literature. Therefore, the DecisionDx-Melanoma Test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the DecisionDx-Melanoma Test was not likely to be 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. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast reduction surgery. In the medical literature, researchers noted that patients with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction. Per the American Society of Plastic Surgeons (ASPS), at least two quality of life signs are required to support an indication for breast reduction surgery. This patient meets the ASPS criteria given the documented presence of back, shoulder, and neck pain, with documented severe shoulder grooving. The two quality of life signs meet the ASPS criteria for breast reduction surgery. For these reasons, the requested breast reduction surgery is medically necessary for this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. Applying the California reconstruction statute, this patient has pain in the neck, shoulders, and lumbar spine, and she reports decreased ability to sleep and perform activities of daily living due to her condition. In this patient, the proposed resection of at least 1500 grams per breast. This supports that the requested breast reduction surgery will improve the patients function and create a more normal appearance. Therefore, the requested breast reduction surgery is reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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.