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

The patient has requested authorization and coverage for proton beam therapy (CPT codes 77520, 77522, 77523, and 77525). Currently, there a paucity of clinical data to support treatment with proton beam radiation in lieu of conventional radiation therapy techniques in the treatment of prostate cancer (Sheets, et al.). One analysis evaluated the comparative effectiveness of intensity modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy for prostate cancer. In the comparison between IMRT and proton therapy, the authors found that the patients treated with IMRT experienced a lower rate of gastrointestinal morbidity, and there were no other significant differences regarding toxicities between IMRT and proton therapy reported. Another analysis of early toxicity compared 421 patients treated for prostate cancer with proton therapy and 842 matched case controls treated with IMRT (Yu, et al.). The authors noted a statistically significant decrease in genitourinary toxicity at six months with proton therapy. However, this difference disappeared by one year and there were no other significant differences in toxicity observed between the two techniques. A position statement released by the American Society of Radiation Oncology (ASTRO) states 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 and state that there is a lack of evidence demonstrating a clinical benefit of proton therapy over standard treatment with photons and IMRT technique. The records provided for review demonstrate the patient has an elevated PSA with Gleason 3+3 adenocarcinoma of the prostate. Based on the patients work-up, he is a candidate for conventional radiation therapy with IMRT or conformal radiation therapy. There is a lack of data to support an indication for proton beam therapy instead of photons due to the patients hydronephrosis or other clinical finding. For these reasons, the requested proton beam therapy (CPT codes 77520, 77522, 77523, and 77525) 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Aimovig 140 mg/mL auto injector. Aimovig (erenumab) is a calcitonin gene-related peptide receptor antagonist approved by the U.S. Food and Drug Administration for the preventive treatment of migraine in adults. The recommended dosage is 70 mg once monthly, with some patients benefitting from a dosage of 140 mg once monthly. As an injectable preventive therapy, erenumab does not require slow dose escalation, provides a rapid onset of therapeutic benefits, and demonstrates favorable tolerability among patients. Researchers found that in patients with chronic migraines, erenumab 70 mg and 140 mg reduced the number of monthly migraine days with a safety profile similar to placebo. The American Headache Society (AHS) indications for treatment with erenumab include a diagnosis of chronic migraines and an inability to tolerate, or an inadequate response to, preventive medications such as topiramate, divalproex sodium/valproate sodium, or amitriptyline. In this case, the patient has a history of chronic migraines that have not responded to multiple oral preventative medications, including Topamax, Depakote, and Elavil. She has found Aimovig effective in decreasing the frequency of migraines in the past. Therefore, Aimovig 140 mg/mL auto injector 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has authorization and coverage for an electrocardiogram (EKG) (CPT code 93000) and a follow-up office visit with a cardiologist (CPT 99213). The U.S. Preventive Services Taskforce does not recommend use of electrocardiography in asymptomatic patients with no history of coronary artery disease. In this patients case, there are no documented recent cardiac symptoms, cardiac physical examination abnormalities, or echocardiographic abnormalities. This patients blood pressure is well controlled, and there are no documented cardiac symptoms or objective cardiac findings to warrant additional cardiac evaluation. Therefore, an EKG (CPT code 93000) and a follow-up office visit with a cardiologist (CPT 99213) are not medically necessary for the evaluation  of this patient.Final Result: The reviewer determined that the requested service is 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 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: The patients parent has requested reimbursement for air ambulance transfer. The records provided for review document that this patient sustained a displaced Salter III fracture of the right ankle as well as and IV fracture of the distal tibia, spiral fracture of the distal fibula, and non-displaced fractures of all metatarsals. Based on current medical literature, this type of injury is treated with closed reduction, which is successful in most cases. The provider recommended transfer for treatment, and closed reduction was not performed prior to transfer. This patients displaced ankle fracture with deformity required immediate closed reduction and possible open reduction. Since treatment was not available at the initial facility, transportation to the receiving facility in an emergent fashion was appropriate. In reviewing the medical records, the transfer was not a request of the patients family. Given these findings, the air ambulance transfer was medically necessary for 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Albinism Multigene Genetic Test Panel by Fulvent. This patient presents with albinism. His provider notes suspicion for oculocutaneous albinism type 1, given the reduced synthesis of melanin in the skin, hair and eyes associated with ocular features of nystagmus, reduced iris pigmentation and retinal pigment, and foveal hypoplasia with significantly reduced visual acuity. Clinical findings of hypopigmentation of the skin and hair, in addition to the characteristic ocular symptoms, are present in many syndromic disorders such as Hermansky-Pudlak syndrome. Due to the considerable phenotypic overlap of different types of oculocutaneous albinism, molecular testing using a multigene panel or comprehensive genome sequencing is preferred for a precise diagnosis. Some patients with clinical features of oculocutaneous albinism, but negative genetic testing, may have other unidentified types of oculocutaneous albinism. Molecular testing is likely to affect this patients management, surveillance, prognosis, and genetic counseling. For these reasons, the requested Albinism Multigene Genetic Test Panel by Fulvent is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  All of the three physician reviewers found the requested Albinism Multigene Genetic Test Panel by Fulvent is likely to be more beneficial for evaluation 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 evaluation 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 genetics and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services two times a week for six to twelve weeks.Clinical Practice guidelines from the American College of Physicians state that for patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment. The guidelines include acupuncture among their specified nonpharmacologic treatments. Vickers and colleagues have also noted that acupuncture is effective for the treatment of chronic musculoskeletal pain. Peer reviewed literature recommends an initial trial of six acupuncture appointments in combination with a conditioning program of aerobic and strengthening exercises. Future acupuncture appointments should be tied to improvements in objective measures to justify an additional six sessions. Clear evidence of objective functional improvement (quantifiable response to treatment) should be established in future exams if more care is requested. Significant objective benefits include a decrease of pain (Visual Analog Scale), increased endurance, increased body mechanics and ability to perform ADLs (activities of daily living), increased ability to perform job-related duties, improved sleep or reduced pain behaviors, amongst others.In this case, the patient has been diagnosed with chronic myofascial pain and suffers from chronic neck, shoulder and back pain. Records reflect that the patient underwent prior acupuncture sessions with benefits. As the patient continues to be symptomatic despite prior procedures, an acupuncture trial for pain management and function improvement would be reasonable at this time. However, the submitted records do not include any extraordinary circumstances that warrant exceeding the practice of an initial trial of six acupuncture sessions, with future acupuncture appointments tied to improvements in objective measures to justify additional sessions. Accordingly, while the requested acupuncture services two times a week for six to twelve weeks are not medically necessary to treat the patients medical condition, an initial trial of six sessions of acupuncture services is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that a portion of the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested coverage for Stelara 390mg infusion followed by 90 mg subcutaneously every eight (8) weeks. Findings: The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients, and the initial response was successfully maintained in the majority of patients for up to 12 months. A significant majority of these patients were able to discontinue steroids. In this case, the patient has tried and failed Remicade, an anti-TNF medication. As Stelara has a different mechanism of action, it is medically indicated for this patient. Therefore, Stelara 390 mg infusion, followed by 90 mg subcutaneously every eight (8) weeks, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg tablet two (2) times daily. Findings:  The physician reviewer found that  There is substantial clinical evidence to support the use of oral Janus kinase (JAK) inhibitors, such as tofacitinib, for treatment of alopecia areata. Jabbari and colleagues performed an open-label pilot study to evaluate the efficacy of tofacitinib. The authors noted that eight out of twelve patients demonstrated at least 50% hair regrowth, as measured by Severity in Alopecia Tool (SALT) scoring. Liu and colleagues performed a study of 90 patients with at least 40% scalp hair loss. The authors found that 77% of patients treated with tofacitinib achieved a clinical response, with 58% of patients achieving greater than a 50% change in SALT score. They also found that tofacitinib was well tolerated, and without serious adverse effects. While contact immunotherapy and systemic steroids may be used to treat severe alopecia areata, these standard therapies may have less satisfactory results and are associated with side effects. Therefore, Xeljanz 5 mg tablet two (2) times daily is likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Xeljanz 5 mg tablet two (2) times daily 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 Xeljanz 5 mg tablet two (2) times daily is 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 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: An enrollee has requested authorization and coverage for right transforaminal epidural steroid injections at L4, L5, and S1.A review of the medical literature reveals transforaminal epidural steroid injections to be more beneficial compared to interlaminar injections. Lumbar epidural steroid injections under fluoroscopic guidance are used very commonly for the treatment of low back and lower extremity radicular pain. These procedures have been shown to be effective for pain relief in the short term and are relatively safe. In this case, the patient has a long history of right sided low back and radicular pain associated with paresthesias radiating down to the foot. The patient has tried and failed other treatments including physical therapy, acupuncture, and medications. There is clinical and MRI evidence of right sided radiculopathy at three levels. Under these circumstances, the requested right transforaminal epidural steroid injections at L4, L5, and S1 are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 reimbursement for proton beam radiation services. There is insufficient data to suggest treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues noted, There were no significant differences in rates of other morbidities or additional therapies between intensity-modulated radiation therapy (IMRT) and proton therapy. Per the authors, among patients with nonmetastatic prostate cancer, the use of IMRT compared with conformal radiation therapy was associated with less gastrointestinal morbidity. Yu and colleagues found no difference in toxicity in patients with prostate cancer treated with IMRT and proton radiotherapy. In this case, a photon-based treatment plan would not be contraindicated for a patient with hydronephrosis, and as the standard of care would be associated with a high level of safety and efficacy. Therefore, proton beam radiation services were 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS).Findings:  The physician reviewer found that patients sustaining mild traumatic brain injuries often report a constellation of physical, cognitive, and emotional symptoms referred to as post-concussion symptoms. The most commonly reported post-concussion symptoms are headache, dizziness, difficulty with memory and concentration, irritability, and depression. The current treatments for post-concussion syndrome include medications, cognitive rehabilitation, psychotherapy, and interdisciplinary collaboration with physical, occupational, and speech therapies. A few studies have considered applying repetitive TMS as a treatment for post-concussion syndrome. Moussavi and colleagues conducted a randomized double-blind study investigating the effect of repetitive TMS on persistent post-concussion syndrome. The authors found that repetitive TMS is a tolerable and potentially effective treatment option for patients within one year of concussion. Koski and colleagues tested the safety, tolerability, and efficacy of repetitive TMS for post-concussion syndrome. The authors concluded that repetitive TMS is safe and well tolerated, which supports additional studies with randomized controlled trials. In this case, the patient presented to the provider with post-concussion syndrome that started at least two years prior. Based on current data, the patients injury occurred more than one year prior to TMS treatment.  Accordingly, the TMS provided was 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 TMS provided was 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 services at issue were 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 neurology 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.