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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensity modulated radiotherapy (IMRT). Upon review of available data, treatment of this patients prostate primary with IMRT is likely more beneficial than standard treatment consisting of three dimensional (3D) conformal radiotherapy or no radiotherapy at all. The patient initially had widespread metastatic disease that is now bone scan negative after about one year of systemic therapy. Studies have suggested at least a failure-free survival benefit and possibly an overall survival benefit in newly diagnosed prostate patients with oligometastatic disease. This patient was initially diagnosed with widespread metastatic disease, but achieved oligometastatic disease after systemic therapy. Thus, the patient meets these criteria. In addition, imaging has demonstrated that the primary disease site is invading the bladder and rectum. Further invasion would likely drastically decrease his quality of life. Prostate radiotherapy is indicated for local control to prevent these complications. A hypofractionated course of 20 fractions to 55-60 Gy with IMRT is appropriate to minimize bladder and rectal side effects. Given this support, the requested IMRT is likely to provide this patient with a superior health outcome when compared to standard available treatment modalities. Final Result: Two of the three 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:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is actively practicing.  All three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of the Inspire upper airway stimulation system.Findings:  Three physician reviewers found that obstructive sleep apnea is an increasingly prevalent clinical problem. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea. Hypoglossal nerve stimulation has been demonstrated to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed continuous positive airway pressure, have nonconcentric airway collapse, an apnea-hypopnea index between 20 and 50, and a body mass index less than 32. The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment for moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with continuous positive pressure therapy and who have appropriate polysomnographic, age, body mass index and objective upper airway evaluation measures. With a body mass index of 28.37, apnea-hypopnea index of 34.1, and nonconcentric airway collapse, this patient meets the criteria. He has failed continuous positive airway pressure therapy, which is the gold standard treatment for obstructive sleep apnea. Thus, implantation of the Inspire upper airway stimulation system is likely to be more effective than other available treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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: Upheld Decision of Health Plan

The enrollee has requested reimbursement for full anesthesia sedation that was used during a colonoscopy. The Health Plan has denied the service at issue as not medically necessary.The 2018 guidelines for sedation and anesthesia in GI endoscopy recommend that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal-to-moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation, as well as those undergoing a procedure that is expected to be uncomplicated or routine. Colleagues performed a systemic review of moderate versus deep sedation for adult colonoscopy cases. The authors concluded that moderate sedation showed comparable safety and effectiveness to deep sedation with respect to patient satisfaction, physician satisfaction, incidence of recall and recovery time. The patient was assessed with an ASA Class I with no use of medications that would make sedation during a colonoscopy more difficult. Moreover, there was no indication in the providers notes that use of a general anesthetic was required to complete the colonoscopy. Final Result: The reviewer determined that the requested service at issue was 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 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: At issue in this case is whether rigid functional orthotics (shoe inserts) are medically necessary for treatment of the patients medical condition. Findings:  The physician reviewer found that he has a recent history of a left foot stress injury to the second metatarsal. The provider noted that compensation due to prior surgeries has allowed for increased lateral left forefoot and midfoot pressure and pain. The patient is using green over-the-counter (OTC) redithotic orthotics, which are not sufficient to support him. The physical examination revealed mild edema and pain with palpation of the left third interspace and plantar left fourth metatarsal head.The medical records and current medical literature support the use of custom orthotics in this clinical setting. He was diagnosed with left fourth metatarsalgia and left third interspace neuroma with pain. The patient is also noted to have scar tissue from prior surgeries and has failed conservative treatment with OTC orthotics. The providers notes that the patient needs more support to the left foot to reduce overpronation, which will defer friction and pressure from the painful areas. The requested equipment is within the current standard of care, which advises that custom functional orthotics may be utilized to offload pressure from the forefoot and midfoot.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 podiatry. 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 enrollee requested authorization and coverage for a surgical procedure to remove excess skin between the thighs (CPT code 15738). The Health Plan denied the procedure as not medically necessary.Bariatric surgery produces rapid, massive weight loss, often leaving patients with excess skin that can be aesthetically disappointing and can present barriers to physical and psychosocial functioning. Steffen and colleagues reported on a survey of patients approximately two years, or six to 10 years after bariatric surgery. The authors found that a greater BMI at survey completion was independently associated with lower satisfaction with excess skin. The records do not include documentation of skin infections or conservative treatment to address the patients rashes. Thus, the requested surgical procedure to remove excess skin between the thighs (CPT code 15738) is not medically necessary for treatment of this patients excess skin. In addition, the requested procedure is not supported as reconstructive in nature. The records provided for review suggest that the patients excess skin is not an abnormal structure of the body, but is the result of the patients obesity. The excess thigh skin is not related to a developmental abnormality, trauma, tumor, infection or disease. Further, the surgery would not improve the patients function, as she will still likely have excess skin causing the same complaints. The patient already has a normal appearance, so any change in appearance would be performed to meet an aesthetic goal. Therefore, the requested surgical procedure to remove excess skin between the thighs (CPT code 15738) is not medically necessary or reconstructive in nature to treat the patients medical condition.Final Result: The reviewer determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheldCredentials/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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the occipital nerve block injection that was received and/or authorization and coverage for future injections. The Health Plan has denied the services at issue as investigational. Findings:  Two out of three physician reviewers found that greater occipital nerve blocks are a simple, safe and effective method, with mild side effects and can be used in patients with inadequate pain relief in spite of medical prophylaxis, or in those who have not tolerated medical treatment. Compared to control intervention, GONB intervention can significantly alleviate pain, reduce the number of headache days and medication consumption, but have no significant influence on the duration of a headache per four weeks for migraine patients. In this case, the record indicates the patients migraines were relatively well-controlled with Cymbalta and the use of Reglan and Benadryl for acute therapy. There is no mention of status migrainosis, failure to respond to triptans, non-steroidal anti-inflammatory drugs or other standard treatments for acute migraine. While occipital nerve block is frequently used to treat refractory migraine in order to break a migraine cycle, and sometimes for migraine prevention, there is no documentation that this was the issue in this case. One physician reviewer found that Nerve blocks, including occipital and trigeminal blocks, are widely accepted in headache medicine. They are commonly used in headache centers for the treatment of acutely severe migraines, as well as preventive treatment.Final Result: The reviewers determined that the services at issue was 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections. Findings:  Two physician reviewers found that the ERCI concluded that evidence from eight systematic reviews and six randomized controlled trials suggested that intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. However, the ERCI cautioned that questions remain about the most effective formulations, which patient populations benefit most, and whether hyaluronic acid injections should be combined with other agents to increase effectiveness. There is a lack of detailed documentation of a recent conservative treatment protocol trial and failure. Therefore, the requested Euflexxa injections are not likely to be more beneficial for treatment of the patient medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is actively practicing.  All three 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

The enrollee requested reimbursement for the hysterectomy that was provided. The Health Plan denied the request as not medically necessary.The American College of Obstetricians and Gynecologists (ACOG) and American Urologic Society (AUS) guidelines state that treatment is indicated for women with symptoms of a prolapse or associated conditions, including urinary, bowel or sexual dysfunction. The patients management options are individualized to symptoms, prior treatments, and quality of life. Patients with a symptomatic prolapse can be managed expectantly, or treated with conservative or surgical therapy. Surgery should be offered to patients with a symptomatic prolapse who have failed or declined conservative management of their prolapse. A laparoscopic hysterectomy with bilateral salpingo-oophorectomy is an appropriate management choice for patients with symptomatic grade 2 pelvic organ prolapse and stress urinary incontinence that seek definitive management. Surgical management with a hysterectomy and sling procedure for symptomatic grade 2 pelvic organ prolapse is well-supported in peer-reviewed medical literature as an appropriate treatment option. This patient presented with symptomatic grade 2 pelvic organ prolapse and stress urinary incontinence. Her condition failed to improve despite treatment with pessary placement and topical estrogen. 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 obstetrics and gynecology 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: At issue is whether Oncotype DX Prostate Cancer Assay that was performed was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy. A review of the records indicates that the patient presented for an evaluation of lower urinary tract symptoms and prostate cancer.Findings:  Three physician reviewers found that medical literature supports the Oncotype DX Prostate Cancer Assay in the evaluation of prostate cancer in certain clinical settings. According to the medical records, the patients anticipated survival is expected to be 10 years or more. The records document an intermediate-risk prostate cancer. For patients with favorable intermediate-risk prostate cancer, National Comprehensive Cancer Network (NCCN) guidelines for therapeutic options include the active surveillance versus radiation therapy versus surgery with radical prostatectomy and pelvic lymphadenectomy. Per NCCN guidelines, men with the low or favorable intermediate-risk disease may consider the use of tumor-based molecular assays, including Oncotype DX Prostate Assay, to assist in determining the treatment decision.Final Result: The reviewers determined that the requested evaluation was likely to have been 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology, and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 24-year-old transgender female diagnosed with gender dysphoria. Findings:  The physician reviewer found that the patient began transitioning in 2017 and has been treated with spironolactone, estradiol and finasteride. The patient was noted to have a good response to hormonal therapy. The patient previously underwent successful laser hair removal of the face. The patient reported the presence of chest hair has caused psychological distress. A physical examination findings included dark terminal hair on the chest with a Ferriman-Gallwey score of two. At issue in this case is whether laser hair removal of chest hair is medically necessary for the treatment of the patients medical condition. There are several critical dermatologic considerations in transgender patients, including hair growth and removal. Body hair, including chest hair, is one of the male features that can cause gender dysphoria. Estrogens also lead to a reduction in quantity and density of body hair, which is often a desired effect. Topical eflornithine and electrolysis may also be options for epilation for interested patients. In this case, the patient has been diagnosed with gender dysphoria and endorsed that chest hair has caused physiological distress. Laser treatment of the patients chest hair will address the source of the patients gender dysphoria in this clinical setting. Therefore, laser hair removal of chest hair 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 psychiatry 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: At issue is whether vertebral axial decompression provided was likely to have been more beneficial for treatment of the patients condition than any available standard therapy. The patient complained of ongoing pain in the neck and low back. The physical examination revealed decreased and painful range of motion in the cervical and lumbar spines. There was tenderness with palpation and muscle spasms noted in multiple areas.Findings:  Two out of three physician reviewers found that the medical literature shows that traction/decompression is not more effective than other standard therapies. Studies indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP. There is only limited-quality evidence from studies with small sample sizes and moderate to high risk of bias.Final Result: The reviewers determined that the requested treatment was 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 chiropractic care 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.