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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for IORT (intraoperative radiation treatment). There is a lack of support in current medical literature for the safety and efficacy of partial breast radiotherapy for the management of early stage breast cancer in patients under the age of 45. While Vaidya and colleagues report in a prospective, open-label, randomized controlled clinical trial with 2,298 patients that IORT during lumpectomy was an effective alternative to external beam radiotherapy (EBRT), trial selection criteria included being aged 45 years or older. In this case, given the relatively young age of this 42-year-old patient, and the use of IORT is not endorsed by expert consensus national guidelines. Rather, there is concern of a heightened risk of in-breast tumor recurrence with the use of IORT, as compared to standard, whole breast radiation therapy. Therefore, IORT is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested IORT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc-One injections for both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior viscosupplementation. Given the patients limited options and based on the current medical literature, the requested services are medically indicated.  Therefore,  Synvisc-One injections for both knees are medically necessary for the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nurtec ODT. The American Headache Society (AHS) notes that in individual pharmacological therapies for acute migraine treatment, non-steroidal anti-inflammatory drugs (NSAIDS) and triptans are effective for the treatment of acute migraine attacks. The U.S. Food and Drug Administration (FDA) describes Nurtec ODT as a calcitonin gene-related peptide (CGRP) receptor antagonist indicated for the acute treatment of migraine with or without aura in adults. In a randomized, double-blind, placebo-controlled trial, Croop and colleagues reported that that the percentage of patients achieving headache pain freedom two hours after a single dose was statistically significantly greater in patients who received Nurtec ODT compared to those who received placebo. The authors further reported that there were no serious adverse events or safety concerns. While the AHS guidelines have not yet been updated to include recommendations on CGRP therapies, Pringsheim and colleagues note that when the initial treatment for an acute migraine does not provide meaningful and sustained benefits, a treatment from a different medication class is typically chosen. In this case, the patient has a history of migraines that have not responded to multiple oral abortive therapies and reported side effects with a triptan. Given that Nurtec ODT is an alternative treatment and a different medication class approved by the FDA for the treatment of acute migraines in adults, the requested medication is medically indicated. Therefore, Nurtec ODT 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT). This patient has a new primary lower quadrant invasive lobular carcinoma that is estrogen receptor (ER) positive, progesterone receptor (PR) positive, and human epidermal growth factor receptor 2 (HER2) negative. The patient previously underwent a course of IORT, and her provider has recommended IORT with partial mastectomy in light of the new imaging findings. Whole breast irradiation is within the standard care for breast cancer patients following surgery since it lowers the risk of recurrence and prolongs survival. IORT is a form of accelerated partial breast radiation therapy (APBI). The current National Comprehensive Cancer Network (NCCN) guidelines suggest that the use of APBI should only be performed within the confines of a high quality, prospective clinical trial. The ASTRO guidelines note that APBI may be appropriate for certain patients that meet specific criteria (Kirby, et al.). However, the follow-up is limited, and studies are ongoing. Based on the current medical evidence, the requested IORT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the IORT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in medical 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vascepa. Rosenson and Eckle note that for patients with high atherosclerotic cardiovascular disease (ASCVD) risk whose triglyceride levels remain at or over 150 mg/dL after lifestyle interventions and optimal therapy to lower low-density lipoprotein cholesterol (LDL-C), there is evidence suggesting that high-dose marine omega-3 fatty acid, specifically icosapent ethyl (brand name Vascepa), reduces cardiovascular risk. In this case, given that the records demonstrated that the patient had established ACSVD and a triglyceride level of 240 mg/dL despite treatment with Lovasa and Praluent, the requested medication is medically indicated. Therefore, Vascepa 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 certifications in cardiovascular disease and in clinical cardiac electrophysiology 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 the Intracept procedure (22899, C9752) at level L4-L5. Fischgrund and colleagues report that patients with Type I or Type II Modic changes treated with radiofrequency ablation of the basivertebral nerve for chronic back pain exhibited significantly greater improvement in Oswestry Disability Index (ODI) at three months and a higher responder rate than sham treated controls. The authors further noted that patients treated with radiofrequency ablation of the basivertebral nerve for chronic back pain exhibited sustained clinical benefits in ODI and Visual Analog Scale (VAS) and maintained high responder rates at two years following treatment. In this case, the patient has chronic low back pain with Modic endplate changes as shown on MRI. Given that current medical literature supports the clinical benefits and durability of the requested procedure for the treatment of isolated low back pain with Modic endplate changes, the requested service is medically indicated. Therefore, the Intracept procedure (22899, C9752) at level L4-L5 is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Zoll LifeVest wearable cardioverter defibrillator (HCPCS K0606). The documented high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter-defibrillators (ICDs) in this group of patients. Current medical literature supports the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular (LV) dysfunction with an ejection fraction of less than or equal to 35%, along with guideline directed medical therapy. Kutyifa  and colleagues report that results from 2,000 patients enrolled in the Prospective Registry of Patients Using the Wearable Defibrillator (WEARIT-II) registry demonstrated that a wearable cardioverter defibrillator can be safely used to protect patients during the period of risk assessment prior to ICD placement. The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend the use of a LifeVest  within 40 days of an acute myocardial infarction, or within 90 days of an initial diagnosis of congestive heart failure with severely reduced ejection fraction, to allow for the potential improvement in the ejection fraction, which may occur spontaneously and with optimal medical therapy, thus obviating the need for an ICD. In this case, a discharge summary dated 3/10/21 reported that the patients ejection fraction was 20%, and the LifeVest prescription was within the 90-day window of an initial diagnosis of congestive heart failure. In this clinical setting, the LifeVest was likely to have been more beneficial than any other available standard therapy in preventing sudden death due to a lethal arrhythmia. Therefore, the Zoll LifeVest wearable cardioverter defibrillator (HCPCS K0606) was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Zoll LifeVest wearable cardioverter defibrillator (HCPCS K0606) at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device 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 reviewers 1 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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 genetic testing services, DecisionDx-Melanoma. In this case, the patient had a diagnosis of melanoma. The results from the service at issue would not have changed the management of this patients thin tumor, which involved a wide local excision and further clinical skin and lymph node surveillance. The National Comprehensive Cancer Network (NCCN) does not recommend the service at issue in the management of thin melanomas and reports that the results from such testing may be inconclusive and are unsubstantiated. Swetter and colleagues note that diagnostic molecular techniques are still largely investigative and while they may be appropriate as ancillary tests in equivocal melanocytic neoplasms, they are not recommended for routine diagnostic use in the setting of cutaneous melanomas. For non-ulcerated tumors transected at a depth of less than 0.8 mm, a reasonable approach would be to perform a repeat biopsy to assess the residual disease. If the subsequent specimen does not reveal a tumor, the recommended treatment and staging may be based on the original Breslow depth. Therefore, genetic testing services, DecisionDx-Melanoma, were not likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the genetic testing services, DecisionDx-Melanoma, at issue were not likely to have been 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 have been more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board-certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for infusions of intravenous (IV) iron sucrose (Venofer 100 mg/5 mL inj) every six months to one year. The records provided for review document that this patients ferritin level was elevated as expected following iron infusions, and these levels have fallen over time. However, the patients most recent level was 70 ng/mL with a normal hemoglobin and hematocrit. Ferritin is an acute phase reactant and numbers can fluctuate for a variety of reasons. The typical cut-off for a low level of ferritin is below 30 ng/mL. The patients laboratory results are not diagnostic of iron deficiency as ferritin levels do not indicate hypoferritinemia at a level of 70 ng/mL. Moreover, the patients symptoms of fatigue, hair loss, and feeling cold are not specific to iron deficiency. All told, the requested infusions of IV iron sucrose (Venofer 100 mg/5 mL inj) every six months to one year are not medically necessary for treatment of this patient. 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 positron emission tomography (PET) scan (CPT 78815). Findings:  The physician reviewer found that (NCCN) guidelines, evaluation with a PET scan can be considered after a computed tomography (CT) scan in high-risk patients to detect extra-pancreatic metastases. Indicators of high-risk patients includes borderline resectable disease, markedly elevated CA 19-9, large primary tumors, or large regional lymph nodes. Wang and colleagues noted that, PET can be used as a valuable diagnostic and predictive tool for pancreatic cancer, but its effect in the staging of pancreatic cancer remains indeterminate. In this case, the patient has a history of pancreatic cancer, and she may be considered for resection if no metastatic disease is found on PET. In this clinical setting, the recommended PET scan is appropriate for initial staging. For these reasons, the requested PET scan (CPT 78815) 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 certifications in medical oncology and hematology 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 and prospective authorization and coverage for skilled nursing facility (SNF) services. Findings:  The physician reviewer found that stroke can significantly affect functionality across many body systems. Interventions can range from exercise to cognitive retraining to learning compensatory strategies. The primary purpose of rehabilitation is to enable patients to function at the highest possible level despite physical impairment. Functional independent measure scores are used in the rehabilitation to assess a patients level of function and scores are compared to assess for response to restorative therapies. The patients functional independent measure score included complete dependence in a majority of factors. Repeat scores on the patients functional independent measure examinations were essentially unchanged. Rehabilitation services should be continued until a patient reaches a plateau. This patients records do not document continued positive response to therapy to support a continuation of services. Furthermore, data on continued rehabilitation interventions are not recommended in the clinical setting of persistent neurological dependence when a patient reaches a plateau or shows no progress. Given these findings, continued SNF services including physical therapy and occupational therapy were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 neurology with subspecialty certification in vascular 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 requested authorization and coverage for L3-4 laminectomy and foraminotomy with exploration and widening of decompression at L4-5 lumbar decompression (CPT 63047). Findings:  The physician reviewer found that the patient has a history of ongoing radiating lower extremity pain. Physical examination shows chronic changes in the left lower extremity, which is supported by a recent electromyography (EMG) study. However, the records provided for review do not include imaging reports documenting ongoing nerve compression to warrant additional decompressive surgery. The current medical literature supports revision decompression when a patients history, imaging, and physical examination findings demonstrate ongoing nerve compression (Martin, et al.; Berry, et al.). Overall, there is a lack of evidence of current nerve compression to support an indication for the requested laminectomy and foraminotomy and lumbar decompression. For these reasons, the requested L3-4 laminectomy and foraminotomy with exploration and widening of decompression at L4-5 lumbar decompression (CPT 63047) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.