Persius/hicric huggingface dataset:
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). IORT has not been demonstrated in peer-reviewed medical literature to be as safe and effective for the management of this patients breast cancer as compared to other accelerated partial breast radiation modalities. The American Society for Radiation Oncology (ASTRO) noted that, Low-energy x-ray IORT for partial breast irradiation should be used within the context of a prospective registry or clinical trial. Similarly, the NCCN recommends partial breast irradiation via brachytherapy or external beam radiotherapy. This patients records do not support a specific indication for IORT instead of conventional radiation therapy approaches. Therefore, the requested IORT is 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 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 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 reviewers 1, 2, and 3 are board certified in radiation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cryoneurolysis for the right knee. Mihalko and colleagues note that per-protocol analysis suggests that preoperative cryoneurolysis in patients with knee osteoarthritis may reduce opioid consumption and improve functional outcomes after total knee arthroplasty (TKA). Dasa and colleagues report that a preliminary retrospective study showed that perioperative cryoneurolysis in combination with multimodal pain management may significantly improve outcomes in patients undergoing TKA. The authors noted that while these results were promising, further investigation of this novel treatment in prospective, randomized trials was warranted. These studies were not conducted at a large volume and were not sufficiently long-term to allow for conclusions and outcomes to be drawn regarding pain reduction and/or functional improvement in the long-term. In a sham-control prospective clinical trial with six-month follow-up, Walega and colleagues reported that cooled radiofrequency ablation of the superior lateral, superior medial and inferomedial genicular nerves, when performed two to four weeks prior to elective TKA as part of a multimodal postoperative pain management regime, had no measurable effect on postoperative opioid use, analgesia use or function in the 48 hours following surgery. The authors further noted that there was no longer term effect on outcome measures at one, three, and six months after TKA. In this case, the patient has a diagnosis of osteoarthritis and is scheduled for a TKA with cryoneurolysis for perioperative pain management. However, there is a lack of evidence in current medical literature supporting the efficacy, safety, and long-term effects of the requested service. Therefore, cryoneurolysis for the right knee 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 cryoneurolysis for the right knee 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. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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: An enrollee has requested reimbursement and prospective authorization and coverage for bilateral occipital nerve blocks every six weeks. Barmherzig and Kingston evaluated the current medical evidence and recommendations for the diagnosis and management of occipital neuralgia. The authors concluded that, Anesthetic block of the greater and/or lesser occipital nerves are often used both diagnostically and therapeutically. However, the authors concluded that the available evidence is limited as most studies are noncontrolled. Urits and colleagues reported that, Conservative treatments such as medications and alternative therapies are first-line. The authors discussed treatment options for patients with refractory symptoms to include corticosteroid injections for short-term relief or as a transitional treatment bridge for patients who may benefit from neuromodulation therapies. In this case, the patient has chronic daily headaches that have been characterized as migraines. The records do not document occipital-based headaches or confirmation of tenderness to palpation over the occiput. The patient has been undergoing Botox injections for the migraines with 50% pain relief. The treating provider has recommended ongoing occipital nerve blocks to manage the patients chronic daily headaches. The most recent peer-reviewed literature regarding occipital neuralgia and treatment options does not confirm that occipital nerve blocks are superior to standard therapy. Moreover, there is a lack of data to support occipital nerve blocks as a method of durable pain relief for this condition. Therefore, bilateral occipital nerve blocks every six weeks were not and are 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 bilateral occipital nerve blocks every six weeks were not and are 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 and 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 anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management 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 Repatha SureClick. Findings: In this case, the patient had multivessel, moderate coronary artery disease but was asymptomatic. Their low-density lipoprotein (LDL) level was not at goal despite maximum doses of rosuvastin and ezetimibe. The patient reported significant side effects to atorvastatin and continued to have mild myalgias on high dose rosuvastatin. While proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors are mainly used in patients with active coronary artery disease or prior events, they may reasonably be indicated in a patient with underlying significant but subclinical multivessel disease who is unable to tolerate conventional maximal statin/ezetimibe therapy or does not reach LDL goals on maximal oral therapy. In this case, the patient underwent a six-month trial of maximal dose rosuvastatin and ezetimibe therapy without reaching their LDL goal, and has known, established coronary artery disease. In this clinical setting, the requested medication is medically indicated. Therefore, Repatha SureClick 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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for outpatient cardiac rehabilitation (CPT 93798).Traditionally, formal cardiac rehabilitation/structured exercise plan has been reserved for patients with established coronary artery disease, prior revascularization, peripheral vascular disease or congestive heart failure. Recent published data, guidelines and expert opinions have focused on the use of exercise training to improve overall cardiovascular function, slow resting heart rates and decrease the life-limiting symptomatology associated with POTS and inappropriate sinus tachycardia syndromes. The psychological component of this syndrome and fear of exercise inducing further symptoms often leads to cardiovascular deconditioning. It is also often improved when an initially supine/sitting, structured exercise program is gradually instituted. Given the published data, expert opinion, and Heart Rhythm Society guidelines, outpatient cardiac rehabilitation can improve cardiac conditioning, decrease symptoms, and improve psychological factors. In this case, the patient continues to have life-limiting symptoms despite lifestyle management. There is sufficient support for the requested services in this clinical setting. Therefore, outpatient cardiac rehabilitation (CPT 93798) is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SPRINT peripheral nerve stimulation (PNS) system. Findings:  The physician reviewer found that presents with chronic low back that is not associated with radiation. He has evidence of mild degenerative disc disease at L4-5 and L5-S1 without signs of high-grade canal or foraminal stenosis. Previous treatments have included non-opioid analgesics, exercises, trigger point injections, and epidural steroid injections, with some relief. The patients records do not report treatment with lumbar medial branch blocks or radiofrequency ablation procedures. The patient has requested treatment with PNS. The current studies assessing PNS for chronic low back pain are limited, with a lack of high-quality prospective randomized control trials and long-term outcome data. Gilmore and colleagues evaluated nine patients treated with PNS of the lumbar medial branches to treat chronic low back pain. The authors found clinically significant reductions in average pain intensity in 67% of patients compared to baseline with sustained results at one-year follow-up. Kapural and colleagues included two patients in their study and reported that PNS can produce sustained pain relief and reduce or eliminate the need for analgesic medications, including opioids. Given the limited data in the peer-reviewed medical literature, the requested SPRINT PNS system is 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 requested SPRINT PNS system 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 device 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. Credentials/Qualifications: Physician reviewer 1 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management 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 authorization and coverage for the RT300 FES Therapy System. Given the debilitating nature of this patients spinal cord injury (SCI), the requested functional electrical stimulator (FES) has the potential to improve her function and quality of life. Luo and colleagues noted that, Due to the physical impairment and mental distress associated with SCI, patients often report reduced participation in physical activities and deteriorating aerobic fitness. The authors noted that, FES-assisted training has been shown to positively impact the cardiovascular functions of SCI patients, primarily by increasing exercise and peak ventilation. Marquez-Chin and Popovic commented that, functional electrical stimulation has evolved into an important therapeutic intervention that clinicians can use to help individuals who have had a stroke, or a spinal cord injury regain their ability to stand, walk, reach, and grasp. All told, the requested the RT300 FES Therapy System is 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 requested the RT300 FES Therapy System 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 device 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 reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a water birth. Findings:  The physician reviewer found that  two randomized controlled trials comparing underwater birth to birth on land have been published. Results suggest minimal benefit to mother and no benefit to the infant. Vanderlaan and colleagues conclude that there is no evidence of increased odds for any neonatal outcome with waterbirth. Moreover, most outcomes are unlikely to change with additional research. At this time, underwater birth requires more rigorous study. In the United States, underwater birth is not supported by American Academy of Pediatrics or American College of Obstetricians and Gynecology. In this case, the patient is a 25-year-old female with no medical or obstetric conditions that increase the risk for serious intrapartum or postpartum complications. However, water birthing is not supported by evidence based literature at this time. Therefore, the requested water birth is not medically necessary for the patients condition (pregnancy).Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients condition (pregnancy). Therefore, the Health Plans denial should be upheld.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom molded foot orthotics for both the right foot and left foot.Custom orthotics have been historically utilized as a conservative standard of care treatment for plantar fasciitis and metatarsalgia. Oftentimes, orthotics will be utilized for bunion and hammertoe pain as well, with specialty pads added to the orthotic to offload painful areas of the feet. Orthotics are useful in the treatment of plantar fasciitis, metatarsalgia, bunions, and hammertoes, as they alter the abnormal biomechanics of the foot, allowing for a more normal foot structure and gait. This will oftentimes alleviate the patients foot pain. In this case, the patient reports painful bilateral plantar fasciitis, difficulty walking, bunion pain and hammertoe pain. The patient is noted to have responded well to custom orthotics therapy in the past. Per the records, her orthotics broke down and became non-supportive. This led to the recurrence of foot pain. Therefore, custom molded foot orthotics for both the right foot and left foot are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Positron emission tomography (PET) scan. Findings:  The physician reviewer found that tage IIA left breast infiltrating ductal carcinoma. The patient has expressed interest in obtaining a PET scan. However, per the National Comprehensive Cancer Network (NCCN) guidelines, in the absence of clinical signs and symptoms suggestive of recurrent disease, there is a lack of indication for imaging studies to screen for metastases. In retrospective cohort studies and meta-analyses, PET scanning has been demonstrated to be more sensitive than conventional imaging and serum tumor markers for early diagnosis of recurrent disease in patients with suspected recurrence. However, the impact on patient outcomes and quality of life has not been established. Routine breast imaging and monitoring for symptoms are recommended for this patients follow-up. Therefore, the requested PET scan is not medically necessary for evaluation and treatment of this patient. Final Result: The reviewer determined that the requested services are 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 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.