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 steroid injection of the lower back. The American Society of Interventional Pain Physicians (ASIPP) guidelines for epidural interventions for chronic spinal pain reviewed the evidence related to the use of epidural steroid injections for discogenic back pain. The ASIPP noted that, The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality randomized controlled trials in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. In this case, the patient has chronic low back pain that is described as axial in nature made worse on flexion of the spine. The patients pain is not radicular in nature and is not associated with any focal neurological deficits. A recent magnetic resonance imaging (MRI) study demonstrated degenerative disc disease and facet joint disease with severe neuroforaminal stenosis. The provider has recommended a lumbar epidural steroid injection to treat the patients discogenic back pain. Current reviews of epidural steroid injection for discogenic back show that there is level 2 moderate evidence supporting this injection for this type of back pain. Given these findings, the requested steroid injection of the lower back is 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Belbuca Film or Hysingla Extended-Release Tablets.At issue in this case is whether the requested Belbuca Film is medically necessary for the treatment of the patients medical condition. If not, are Hysingla extended-release tablets medically necessary to treat the patients medical condition? The 2016 Centers for Disease Control (CDC) guidelines on opioid therapy for non-cancer pain state, When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to 90 MME/day or carefully justify a decision to titrate dosage to 90 MME/day. Federation of State Medical Boards notes, Prescribers should use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. Webster and colleagues recommended that buprenorphine be considered before some Schedule II, III, or IV opioids in patients with a favorable risk/benefit profile on the basis of metabolic factors, abuse potential, and tolerability and that buprenorphine be continued during the perioperative/trauma period. The most recent peer-reviewed literature validates the efficacy of buprenorphine for use in chronic pain population, and current consensus guidelines support using buprenorphine as first-line treatment over traditional full opioid agonists due to better safety profile, tolerability and non-inferior analgesic effects. In this case, the patient has reported chronic non-cancer related pain. The provider has prescribed Belbuca Film for the treatment of the patients endometriosis and chronic pain. The prescribed therapy is consistent with the most recent 2016 CDC guidelines on opioid therapy, which advocate starting patients on the lowest effective dose of opioids as part of a multimodal pain management strategy. Of note, prescribing two long-acting opioid therapies concurrently is not recommended by the guidelines. In sum, the requested Belbuca Film is medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined 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 anesthesiology with sub-specialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for chemical denervation of the internal anal sphincter with Botox injection. Current medical literature supports the use of Botox injections for the treatment of anal fissures. The American College of Gastroenterology clinical guideline for management of benign anorectal disorders reports that the injection of botulinum toxin into the internal anal sphincter allows healing in 60% to 80% of fissures, and at a higher rate than placebo. Bobkiewicz and colleagues report that botulinum toxin is an accepted method for the management of chronic anal fissure. Sahebally and colleagues found that botulinum toxin has fewer side effects than topical nitrates with similar efficacy. In this case, the patient had an anal fissure with rectal bleeding. In this clinical setting, a botulinum toxin injection of the anal sphincter was medically indicated. Therefore, chemical denervation of the internal anal sphincter with Botox injection was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin.Findings: The U.S. Food and Drug Administration (FDA) has approved somatotropin to treat idiopathic short stature (ISS), defined as standing height below -2.25 SDs without identifiable cause. Standard of pediatric endocrine care for suspected growth disorders includes documentation of testicular volumes to monitor pubertal timing and tempo, and brain magnetic resonance imaging (MRI) with and without contrast to exclude intracranial masses. In this case, this patient displays normal growth velocity, current height above -2.25 SDs, and predicted adult height within 2 SDs of mid-parental target height. Their growth pattern and bone ages have been consistent with mild constitutional delay of growth and development as well as the familial growth pattern. Therefore, Nutropin AQ NuSpin is not medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 LifeWatch extended heart monitoring system (external electrocardiographic recording). Steinberg and colleagues note that extended ambulatory monitoring may improve diagnostic yield, especially since atrial tachyarrhythmias are more likely to cause pre-syncopal symptoms in patients with underlying cardiomyopathy. In this case, the patient has a depressed ejection fraction and would be a candidate for an implantable cardioverter-defibrillator without improvement. The records note that the patients clinical symptoms include dizziness and pre-syncope along with documented non-sustained ventricular tachycardia and atrial tachycardias. In this clinical setting, given that information regarding the frequency and burden of the various arrhythmias, including the correlation of specific types of arrhythmia with clinical symptoms, is needed in order to evaluate the appropriateness of medical and ablative therapy, the requested equipment is medically indicated. Therefore, a LifeWatch extended heart monitoring system (external electrocardiographic recording) is medically necessary for the 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.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 vedolizumab (Entyvio) infusions (standard loading and maintenance dosing).According to American Gastroenterological Association and American College of Gastroenterology clinical guidelines, Entyvio is recommended as a first-line therapy for ulcerative colitis. Entyvio is effective for ulcerative colitis, with minimal side effects. Entyvio is an integrin antagonist specific to the gastrointestinal tract. It has a different mechanism of action than immunosuppressants and anti-tumor necrosis factor (TNF) agents, such as Remicade, for ulcerative colitis. In this case, Entyvio is more appropriate than anti-TNF medications because the patient has had pancreatitis with the use of infliximab. Without treatment, the patient is at risk for complications, such as toxic megacolon and disease flare. For these reasons, vedolizumab (Entyvio) infusions (standard loading and maintenance dosing) are 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 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 Forteo 600 mg/2.4 mL 20 mcg subcutaneous by self-injection, with 11 refills. Findings:  The physician reviewer found that (FDA) approves the use of Forteo for the treatment of postmenopausal women with osteoporosis at a high risk for fracture. Babu and colleagues report that teriparatide (brand name Forteo) has been shown to increase bone mass and prevent fractures in osteoporotic bone. In this case, the patient has sustained atraumatic fractures and is at an increased risk of future fractures. In this clinical setting, the requested medication is medically indicated. Therefore, Forteo 600 mg/2.4 mL 20 mcg subcutaneous by self-injection, with 11 refills, 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a full hospital admission and stay, post gallbladder surgery. Bagla and colleagues note that cholecystectomy remains the only definitive therapy for acute cholecystitis and that current guidelines recommend treatment on the basis of disease severity at presentation. Thangavelu and colleagues note that management of acute cholecystitis by emergency physicians should be made based on patient's clinical status. In this case, the patient presented with acute pain for five days, and required extended evaluation with a HIDA scan that suggested acute cholecystitis for which he was treated surgically. The patient had a drain placed during surgery, was monitored for evidence of bleeding, and continued on intravenous pain medication. One day postoperatively, the patient appeared stable, was started on a regular diet, transitioned to oral pain medications, had his drain removed, and was discharged to his home. In this clinical setting, acute inpatient admission for the evaluation, treatment, and postoperative care of acute cholecystitis was medically indicated. Therefore, the full hospital admission and stay, post gallbladder surgery, was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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 sleep study. Findings:  The physician reviewer found that the records provided for review document that this patient has mild obstructive sleep apnea (OSA) by home sleep study, which demonstrated an apnea/hypopnea index (AHI) of 14 episodes per hour, which is borderline moderate OSA. Home sleep studies can underestimate the severity of OSA but are useful to rule in OSA without regard for severity. As this patient is symptomatic with excessive daytime sleepiness, positive airway pressure (PAP) therapy is indicated. The American Academy of Sleep Medicine (AASM) state that providers should use PAP, compared to no therapy, to treat OSA in adults with excessive sleepiness. The AASM guidelines recommend in-laboratory titration for effective PAP therapy. Therefore, the requested sleep study (CPT 95811) is medically necessary for 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 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 donut lift of left breast and reduction and full lift of the right breast, and placement of breast implants four to six months after the first surgery. Ellart and colleagues report that tuberous breast deformity is a breast anomaly with different clinical signs. The most consistent sign is the constricting ring at the base of the breast with frequently associated breast asymmetry. There is also deficiency in the horizontal and/or vertical dimensions of the breast and often herniation of breast parenchyma toward the nipple-areola complex with areola enlargement. This patient presents with marked breast asymmetry with bilateral tuberous breast deformity. No functional problems are documented as marked breast asymmetry with bilateral tuberous breast deformity is without functional significance. Given the lack of functional problems related to the patients breast asymmetry, the requested donut lift of the left breast and reduction and full lift of the right breast, and placement of breast implants four to six months after the first surgery are not supported as medically necessary. 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. This patients marked breast asymmetry with bilateral tuberous breast deformity is an abnormal structure of the body caused by a developmental abnormality. The requested surgical procedures to correct the patients breast asymmetry is for the purpose of creating a normal appearance, to the extent possible. The requested surgery would provide more than a minimal improvement in the appearance of the patient. The proposed donut lift of the left breast and reduction and full lift of the right breast are reconstructive in nature per the California reconstructive surgery statute and are thus medically necessary. Per the California reconstructive surgery statute, the patients marked breast size asymmetry is an abnormal structure of the body caused by a developmental abnormality. A surgical procedure to correct the issue by placement of breast implants four to six months after the first surgery is for the purpose of creating a normal appearance, to the extent possible. The surgery would provide more than a minimal improvement in the appearance of the patient. The proposed placement of breast implants four to six months after the first procedure is reconstructive in nature per the California reconstructive surgery statute and is thus medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing (CPT 83695 and 82172). The records provided for review document that this patients low density lipoprotein (LDL) cholesterol was 187 mg/dL on routine lipid panel testing. Her provider recommended advanced lipoprotein testing. However, there is a lack of accepted clinical studies demonstrating that strategies to correct the residual risk identified by novel lipoprotein testing, such as the advanced lipoprotein analysis, will further reduce a patients cardiovascular risk. The peer-reviewed medical literature has not demonstrated that advanced lipoprotein testing adds significant information to data yielded from a standard fasting lipid panel. Given these findings, the advanced lipoprotein testing (CPT 83695 and 82172) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the advanced lipoprotein testing (CPT 83695 and 82172) 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 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: An enrollee has requested authorization and coverage for Botox injections.Thoracic outlet syndrome is a difficult condition to diagnose, principally arising from an absence of other causes for arm/shoulder pain as well as typical symptoms and provocative physical maneuvers. In an effort to provide diagnostic accuracy, selective injection of the scalene muscles as well as the pectoralis minor muscle with local anesthetics has been useful in some cases. Guided injection of Botox has also been investigated as a means of both diagnosis and treatment. A study by Salhan and colleagues suggests improvement with Botox injections, notably from a center well-established in the treatment of thoracic outlet syndrome. Botox injections are generally safe with few reported complications. The procedure should be viewed as medically necessary for diagnostic as well as therapeutic purposes. In this case, the patient has been diagnosed with thoracic outlet syndrome. There is sufficient support for the requested services in this clinical setting. Therefore, Botox 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 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.