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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for diagnostic facet injections of C2-3, C4-5 right side, and C6-7 bilateral. In a systematic review, Chou and colleagues report that despite an overall paucity of high quality studies and more specifically the lack of investigations related to thoracic facet joint injection, there is evidence supporting the use of therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine. Cohen and colleagues conclude, Facet injections appear to have little long-term utility, though they may provide prognostic value compared to control injections before radiofrequency ablation. Multicenter randomized trials are needed to ascertain the best way to diagnose facet joint pain, confirm the efficacy of radiofrequency ablation, and determine which patients benefit most. Manchikanti conclude, Based on the present assessment for the management of spinal facet joint pain, the evidence for long-term improvement is Level II for lumbar and cervical radiofrequency neurotomy, and therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine. In this case, the patient reports neck pain that radiates down the right side of his neck and into his right shoulder that is aching and sharp. An examination showed tenderness in the midline of the cervical spine and noted the following for the patients cervical range of motion: flexion 20 degrees, extension 20 degrees, left and right lateral flexion five degrees, and left and right lateral rotations 75 degrees. The patient had full strength and intact sensation in the bilateral upper and lower extremities. Deep tendon reflexes were noted as 0/4 in the bilateral upper and lower extremities. In this case, the records do not include detailed documentation regarding facet-mediated pain. The records include plausible evidence of radiculopathy and note that the patient has undergone previous facet joint injections. In this clinical setting, current medical literature does not support the efficacy of medial branch nerve blocks. In this case, given that there is limited published, large-scale, long-term peer-reviewed literature demonstrating the safety and efficacy of repeat facet injections, the requested services are not medically indicated. Therefore, diagnostic facet injections of C2-3, C4-5 right side, and C6-7 bilateral are 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 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 Botox injections into the bilateral hip adductors. The requested Botox injections into the bilateral hip adductors are not medically necessary to treat the patients medical condition. Van Lith and colleagues concluded, Bilateral botulinum toxin A treatment and subsequent stretching of the hip adductors may improve gait and reactive lateral stepping in patients with pure hereditary spastic paraplegia. Cioncoloni and colleagues reported, A meaningful improvement in walking performance can be obtained in chronic spastic patients after botulinum neurotoxin A injection into several muscles, specifically the hip adductors. Duran-Hernandez and colleagues noted, Osteoarthritis of the hip is a low-grade inflammatory disease of multiple etiology that has a limited conservative management and is insufficiently explored. The application of botulinum toxin type A produces in the applied muscle a temporary, delimitable and reversible flaccid paralysis, which applied in a strategic way achieves to reduce mechanical stress and pain. The authors concluded, The treatment with botulinum toxin type A provides a conservative and safe option for the management of symptoms and physical restraint caused by hip osteoarthritis.This patient has been treated for bilateral hip joint stiffness. She presented with tight hip adductors bilaterally, which are also painful. She underwent previous hip replacement surgery. More recently, she has been noted to have difficulty with tight hip adductors, with pain on attempted abduction. Per the records, hip abduction is only about 15 to 20 degrees in flexion. The hip adductor longus is tight bilaterally. She did not appear to have significant tightness of her gracilis. While there may be support for the use of these injections to treat certain disorders, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective or safe treatment for the patients noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested Botox injections into the bilateral hip adductors are 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 CDx genetic testing. Understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next-generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise. Patients with inflammatory and metastatic breast cancers benefit from NGS to identify markers that may indicate benefit from targeted treatment. In this patients case, the records document that Foundation One testing was previously performed. Thus, Guardant360 CDx genetic testing was not indicated. Both tests were not needed in this patients case. Therefore, Guardant360 CDx genetic testing performed by Guardant Health, Inc. was not likely to have been more beneficial than any available standard treatment for the patients medical condition.Findings: Two out of three medical experts decided that Guardant360 CDx genetic testing performed by Guardant Health, Inc. was not likely to have been more beneficial for 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 reviewer 1 is board certified in in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for placement of a perirectal spacer. Review of available literature including publications arising from systematic reviews, randomized controlled trials, non-randomized data, and national guidelines support the benefit to patients of placement of perirectal spacers to reduce acute and late toxicity of definitive radiation therapy, including standard fractionation, hypofractionation, stereotactic body radiation therapy, stereotactic body radiation therapy, and brachytherapy. Placement of perirectal spacers has been demonstrated to reduce the incidence of rectal toxicity and sexual dysfunction. These reductions in toxicity are more pronounced in men who undergo stereotactic body radiation therapy, as the incidence of late toxicity relative to higher dose per individual fraction is higher than for standard fractionation. Therefore, the placement of a perirectal spacer was likely to have been more beneficial than any available standard therapy.Findings: Three out of three medical experts decided that the placement of a perirectal spacer was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The medical experts determined that the service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a LifeVest Wearable Cardioverter Defibrillator provided by Zoll Services. The current medical records do not support the device at issue in this clinical setting. This patient presented with symptoms of congestive heart failure. He was found to have a dilated cardiomyopathy (left ventricular ejection fraction of 25%) and was started on standard goal directed medical therapy. Cardiac catheterization reported normal coronary arteries. In this circumstance, a wearable defibrillator was utilized for primary prevention. Wearable defibrillators have not been shown to be of benefit in this population of patients. The study by Olgin and colleagues failed to show a reduction in sudden cardiac death in the group treated with external defibrillators. A recent meta-analysis concluded that additional controlled trials are needed to justify the use of a wearable defibrillator in the primary prevention setting. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation. Therefore, the LifeVest Wearable Cardioverter Defibrillator provided by Zoll Services was not likely to have been more beneficial than any other available standard therapy for treatment of the patients condition.Findings: Two out of three medical experts decided that the LifeVest Wearable Cardioverter Defibrillator provided by Zoll Services was not likely to have been more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: The reviewers determined that the device at issue was not likely to have been 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 sub-specialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: The patient has requested authorization and coverage for Dupixent 300 mg/2 mL Pen injectors. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with moderate-to-severe atopic dermatitis when symptoms are not adequately controlled with topical therapies. Boguniewicz and colleagues defined moderate-to-severe atopic dermatitis as greater than 10% body surface area (BSA) involvement and/or involvement of highly visible areas or those important for function and significantly impaired quality of life. This patients records document moderate-to-severe atopic dermatitis with almost 35% BSA involvement. In addition, Dupixent has high quality clinical trial evidence demonstrating its safety and efficacy in the treatment of patients with atopic dermatitis (Siegels, et al.). Systemic cyclosporine is not recommended for long-term use due to toxicities and is an immunosuppressive that has been associated with increased infection risk. Additionally, immunosuppressives such as prednisone, methotrexate, mycophenolate, azathioprine, and cyclosporine can reduce the response to vaccinations. This patients provider noted that the patient has failed topical steroids with triamcinolone, systemic steroids, and hydroxyzine. Considering the patients 35% BSA involvement, topical calcineurin inhibitor application is not recommended. For these reasons, the requested Dupixent 300 mg/2 mL Pen injectors are medically necessary for 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 dermatology 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 skilled nursing facility (SNF) services including 90 minutes of physical therapy and occupational therapy per day. Meningioma is the most frequent primary tumor of the central nervous system with known progression or recurrence in a subset of these tumors following resection (Gupta, et al.). Treatment options for recurrent meningiomas include surgery and radiation. Systemic therapies have been found to have limited efficacy in this clinical setting (Apra, et al.). This patients records document persistent deficits including mild cognitive deficits and left hemiparesis following surgical debulking of a recurrent meningioma. The patients cognitive deficits have negatively affected their insight and processing abilities. The patients left hemiparesis and obesity have limited their functional progress with respect to self-care and basic mobility. Despite one month of rehabilitation services, the patient continued to require maximum to total assistance for their self-care and basic mobility needs. There is a lack of documentation of significant neurological recovery since the patient started rehabilitation services. Thus, reintroduction to rehabilitation services from the custodial care setting to the SNF treatment level of care is not anticipated to result in improved function or outcomes for this patient. In addition, the patient does not have any reported skilled nursing needs. For these reasons, the requested SNF services including 90 minutes of physical therapy and occupational therapy per day are 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 physical medicine and rehabilitation 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 Trikafta. The U.S. Food and Drug Administration (FDA) approves the use of Trikafta for the treatment of cystic fibrosis in patients who have at least one F508del mutation in the CFTR gene. Heijerman and colleagues report that in a four-week treatment period, triple therapy with elexacaftor, tezacaftor, and ivacaftor provided clinically robust benefit in FEV1 and in symptom-related quality-of-life compared with double therapy with tezacaftor and ivacaftor alone, with a favorable safety profile. Given that current medical literature supports the efficacy of Trikafta in this clinical setting, the requested medication is medically indicated. Therefore, Trikafta 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 pulmonary diseases 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 authorization and coverage for Xifaxan 550 mg (one tablet by mouth three times daily for 14 days, quantity 42 tablets). As noted in the medical literature, small intestinal bacterial overgrowth (SIBO) is a recognized cause of gastrointestinal distress and is likely a primary contributing factor to irritable bowel syndrome (IBS). Per the American Gastroenterological Association (AGA) practice guidelines on SIBO, no single antibiotic regimen is recommended (Quigley, et al.). The U.S. Food and Drug Administration (FDA) has approved rifaximin (Xifaxan) for the treatment of adult patients with irritable bowel syndrome, diarrhea predominant (IBS-D). In addition, Xifaxan has been demonstrated to be one of the most effective medications in the treatment of SIBO in adult patients (Gatta and Scarpignato). However, the treatment of this pediatric patients methanogenic SIBO is less well studied. Ghoshal and colleagues found that combination of both rifaximin and neomycin is more effective in decreasing methane production than either antibiotic alone. Scarpellini and colleagues reported on non-controlled prospective data demonstrating the effectiveness of Xifaxan in the treatment of pediatric patients with SIBO. Avelar Rodriguez and colleagues concluded that Xifaxan has demonstrated safety in a greater number of participants and studies. Considering this patients age and the presence of methane on her lactulose breath test, Xifaxan is likely the safest and most effective treatment choice, especially in combination with neomycin. All told, the requested Xifaxan 550 mg (one tablet by mouth three times daily for 14 days, quantity 42 tablets) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certification in pediatric gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for iontophoresis. Current medical literature on iontophoresis for musculoskeletal abnormalities focuses on calcific tendinosis, which this patient does not have. Ling and Lui describe iontophoresis as a procedure which transmits localized dexamethasone via an electrical current deep to the skin into the inflamed tendon. There is a lack of data in current medical literature supporting the efficacy of iontophoresis for the treatment of musculoskeletal abnormalities, including tenosynovitis, and a lack of significantly large, double-blind, placebo-controlled studies comparing iontophoresis treatment to sham treatment with respect to tenosynovitis. In this case, the patient has insertional posterior tibial tenosynovitis. While the records note that the patient has tried and failed numerous conservative treatments, given that the records do not document trial and failure of cast immobilization, controlled ankle motion (CAM) boot immobilization, or a lace-up ankle brace that may allow for pain reduction, the requested equipment is not medically indicated. Therefore, iontophoresis is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is licensed D.P.M., board certified in podiatry, 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.