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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for placement of SpaceOAR hydrogel. The records provided for review demonstrate that this patient presented to his provider with an elevated prostate specific antigen (PSA). Biopsy revealed Gleason score 3+4 prostate cancer. His provider recommended SpaceOAR hydrogel placement for use with radiation therapy. The use of the SpaceOAR hydrogel was within standard of care in this patients clinical setting. Recent data has demonstrated that the incorporation of SpaceOAR hydrogel yields superior clinical outcomes as compared with definitive radiotherapy without the use of SpaceOAR hydrogel. SpaceOAR was shown in a phase III randomized prospective setting to minimize the risk for radiation-induced urinary and bowel side effects. Moreover, the use of SpaceOAR hydrogel is supported by the National Comprehensive Cancer Network (NCCN) for patients with prostate cancer undergoing radiation therapy. For these reasons, placement of SpaceOAR hydrogel was 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 placement of SpaceOAR hydrogel was 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 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for olopatadine HCL eye drops. Findings: Based on the records provided for review, this patient presents with eye symptoms of burning, itching and drainage. The patient has a history of bilateral conjunctivitis as well as rhinitis. Although treatment with olopatadine is indicated for this patients condition, there are several standard alternatives available for treatment. Medical studies demonstrate equivalence of many of these medications with olopatadine. There is a lack of support in the medical records that the patient experienced adverse reactions to multiple medications and therefore is a good candidate for treatment with one of the other formulations. For these reasons, the requested olopatadine HCL eye drops are not medically necessary for this patient. Final Result: The reviewer determined that the requested services medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing (CPT 82172 and 83695). The records document that this patient has mild, subclinical atherosclerosis as seen on radiologic studies. She is at intermediate 10-year risk for symptomatic cardiovascular disease and is being treated with statin and aspirin therapy. Her low-density lipoprotein (LDL) cholesterol is close to goal on a low dose statin and her high-density lipoprotein (HDL) is high. As she has some mild but established vascular disease and hypertension treated with statin therapy. Advanced lipoprotein testing may be considered for additional cardiovascular risk evaluation when  a patients cardiovascular risk is borderline or intermediate. In this case, the patient has mild but established vascular disease and is already being actively treated with statin therapy (Arnett, et al.). Additional measurements with advanced lipid profiles do not change the guideline-directed therapeutic plan of treating to appropriate LDL goals with statin therapy. Accordingly, the advanced lipoprotein testing (CPT 82172 and 83695) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the advanced lipoprotein testing (CPT 82172 and 83695) was not likely to be 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 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 internal medicine with subspecialty certification in cardiovascular disease 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 patients parent has requested authorization and coverage for a bilateral mastectomy. Chest surgery in transgender male minors is a common treatment for gender dysphoria. The World Professional Association for Transgender Health (WPATH) states, Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. Researchers reported that chest surgery in transgender male minors was a safe and effective treatment for gender dysphoria, noting, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. In this case, the patient has gender dysphoria and has spent ample time living in the desired gender role and has begun testosterone treatment. The patients provider reports that the requested service is medically indicated for the treatment of this patient. Therefore, a bilateral mastectomy 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 with expertise in transgender health 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 platelet-rich plasma (PRP) injection. Researchers concluded that the standard of care for lateral and medial epicondylitis remains conservative management with non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and bracing. Newer treatments for epicondylitis are under development, and initial research supports continuing to optimize PRP variables, collagen-producing cell treatments, and stem cell treatments. Voids in the literature, particularly regarding PRP protocols, prevent the recommendation that PRP treatments are safe and effective. This patient presents with a history of persistent right lateral epicondylitis for the past year. He reports that his elbow pain is debilitating. Clinical examination findings are consistent with imaging evidence of low grade intrasubstance interstitial tear of the origin of the common extensor tendon. He has failed to achieve adequate improvement with activity modification, physical therapy, home exercise program, tennis elbow strapping, and anti-inflammatory medications. He underwent two cortisone injections without significant or sustained improvement. Current evidence based medical literature indicates that PRP is promising for the treatment of lateral epicondylitis. However, there is a paucity of clinical data demonstrating that PRP provides superior health benefits as compared to standard treatment modalities. Therefore, the requested PRP injection 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 PRP injection 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients representative has requested reimbursement for air and ground ambulance transportation services. The records document that this patient had severe, end-stage cardiomyopathy secondary to ischemic heart disease. He was not considered a candidate for conventional open valve surgery and initially was considered for percutaneous mitral valve clip in Pennsylvania. He remained symptomatic and his providers recommended cardiac transplant evaluation. The advanced heart failure team in recommended transfer to California, due to the lack of social supports, which would prevent him from being placed on a donor list in Pennsylvania. As the closest transplant center to his home was Cedars Sinai in California, he required transport for further treatment and evaluation. He had Class IV congestive heart failure, dependent on milrinone inotropic support, oxygen and intravenous diuretics. Moreover, the patient had difficulty lying flat. Given the severity of his clinical cardiac condition, travel without medical support by commercial aircraft or ground ambulance would have been be clinically unsafe. Thus, air ambulance was the safest transport option for this patient. Left ventricle assist device (LVAD) implantations are different procedures than other cardiac procedures such as stent, a valve clip or even bypass surgery, which require short-term care. Implantation of an LVAD as a bridge to transplant requires the patient to remain close to the implanting center for close ongoing follow-up. Further, strong social support was needed given the importance of follow-up, psychological concerns, compliance with longer-term treatments. Based on these findings, the air and ground ambulance transportation services were medically necessary for this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Percocet. Findings: Guidelines for prescribing opioid medications assist providers in making decisions regarding initiating, adjusting and discontinuing of opioid therapy. The guidelines were not intended to provide a hard limit to the prescribing of opioid medications for chronic pain patients. To clarify these issues, the CDC recently announced that providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. Other guidelines noted that, continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Guidelines opined that dosage should be maintained as low as possible and continue[d] only if clear and objective outcomes are being met. In this case, the patient has chronic pain related to cervical radiculopathy, cervicalgia, and degenerative cervical disc disease. They have a previous history of cervical fusion. They have attempted multiple forms of conservative non-opioid therapy including epidural steroid injections, and physical therapy. Their CURES reports have been consistent with therapy. The provider has established that the patients chronic neck pain is severe and there is support of the diagnosis on cervical magnetic resonance imaging (MRI) showing previous neck fusion. The provider has outlined a plan to wean the patients Soma and opioid medications by performing additional cervical epidural steroid injections. The providers notes do not show any concerns regarding evidence of adverse drug reactions or aberrant behavior. The patients appeal statement states that the medications allow them to functional with their activities of daily living by managing their pain. Based on the available medical records for review and the national guidelines and literature reviews, Percocet 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 board certified in anesthesiology with subspecialty certification in pain management 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 patients parent has requested authorization and coverage for brand medication, Norditropin FlexPro. The U.S. Food and Drug Administration (FDA) has approved GH therapy for patients with idiopathic short stature. This patients growth chart and clinical records support that this patient initially met FDA approved criteria for treatment with GH therapy due to idiopathic short stature with height z-score below -2.25 SDs from about age seven to age nine, despite treatment with somatotropin during some of this timeframe. Absent true puberty, this patients height z-score eventually improved significantly into the normal range while receiving somatotropin therapy, a clinical response displayed by a minority of prepubertal patients with idiopathic short stature. Her recent predicted adult height remains more than 2 SDs below the mean for North American women. Her growth pattern and bone ages have been consistent with her familial pattern of growth and development and consistent with both benign premature adrenarche and familial idiopathic short stature. Somatotropin therapy is indicated to help the patient attain a final adult height z-score above -2 SDs for North American women. However, this patients records lack documentation to meet the criteria for treatment with GH therapy. Specifically, there is no record of karyotype testing to exclude mosaic Turner syndrome, or brain MRI with and without gadolinium contrast obtained either before or after initiation of somatotropin. In the absence of this data, the requested Brand medication, Norditropin FlexPro is not medically necessary for 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 board certified in pediatrics with subspecialty certification in pediatric endocrinology 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 an implantable cardioverter defibrillator (CPT-33249). Findings:  The physician reviewer found that patients with extensive late-gadolinium enhancement may be at increased risk of sudden death, independent of other high-risk features, with implications on management strategies including consideration for primary prevention implantable cardioverter defibrillator therapy. In this case, the patient has several risk factors for sudden death given her history of hypertrophic cardiomyopathy, recurrent syncopal episodes, inappropriate blood pressure response to exercise, a left ventricular aneurysm, and diffuse delayed gadolinium enhancement on MRI. Given the current medical literature, the requested device is medically indicated. Therefore, an implantable cardioverter defibrillator (CPT-33249) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for second neuropsychological examination. This patient was administered a battery of neurocognitive tests to evaluate cognition, memory, attention, and concentration. All of the tests administered to the patient are widely used and are considered to be valid and reliable measures of their focus. The tests have also been demonstrated to yield consistent results when administered by different providers. This patients personality profile, according to the Minnesota Multiphasic Personality Inventory (MMPI), indicates an unusually high number of symptoms endorsed in the areas of somatic, psychiatric, and cognitive functioning. This result suggests that the patient may be overly focused on these issues, which may further compound his distress and lead to further impairment. Testing also revealed evidence of severe depression and moderate anxiety. The neuropsychological testing included the Wechsler Adult Intelligence Scale Fourth Edition (WAIS-IV), which is the most common test of neuropsychological function. The Wechsler Memory Scale Fourth Edition (WMS-IV) is a widely used clinical instrument designed to assess domains of memory, including short-term, long-term, and working memory. Delis-Kaplan Executive Function System (DKEFS) is sensitive to frontal-lobe dysfunction and executive-function deficits associated with a variety of neurological, developmental, and psychiatric disorders. The Trail Making Test (TMT) is a measure of attention, processing speed, and mental flexibility. On review of this patients test results and reliability of the testing utilized, there is a lack of an indication for repeat neuropsychological testing. Given these findings, the requested second neuropsychological examination is not medically necessary for 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment RT300 functional electrical stimulation (FES) therapy system.Findings:  The physician reviewer found that The records provided for review document that this patient sustained injuries in a motorcycle accident with incomplete spinal cord injury at the C5 level and traumatic sensory incomplete ASIA impairment scale grade B spinal cord injury at the L1 level. The patients provider recommended use of an RT300 FES therapy system, which provides passive exercise in patients with neurological weakness by using strategically placed electrical stimulation leads to activate weakened leg muscles to drive a stationary cycle. The current medical literature and clinical studies have not demonstrated that the device improves functional outcomes or neurological recovery in patients with spinal cord injury (Hofer and Schwab). Studies have not reported that use passive exercise with FES provides significant of health outcomes with respect to the cardiovascular, pulmonary, musculoskeletal or other organ systems (Ralston, et al.; Mayson and Harris). For these reasons, the requested durable medical equipment RT300 FES therapy system is not medically necessary for this patient. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer 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.