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

An enrollee has requested reimbursement for proton beam radiation therapy services. The use of proton therapy is an accepted radiation technology with proven efficacy and tolerability in the treatment of certain conditions such as base of skull chordomas and chondrosarcomas. Due to the sharp dose fall off, this allows for high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. In this case, the provider noted that the patient underwent proton beam radiation therapy for the treatment of World Health Organization (WHO) grade II oligodendroglioma. However, there is a paucity of published data to support proton therapy for gliomas. The available data is limited and represents small studies, dosimetric comparisons, and studies including various tumor types. The current National Comprehensive Cancer Network (NCCN) guidelines describe proton therapy for grade 3-4 gliomas specifying that proton therapy can be considered for good long-term prognosis to better spare uninvolved brain and preserve cognitive function. The NCCN guidelines do not discuss proton therapy for lower grade gliomas, which are generally treated to lower doses than higher grade gliomas. Based on these findings, the proton beam radiation therapy services provided were 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 proton beam radiation therapy services provided were 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 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 internal medicine with subspecialty certifications in medical oncology and hematology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for percutaneous implantation of neurostimulator electrode array, epidural procedure. Researchers completed a study of 12 patients who underwent high cervical lead placement of a spinal cord stimulator in the epidural space. The authors found that, When compared with the baseline, the mean reduction achieved in the postoperative average numeric rating scale was 4 points, accounting for a 57.1% pain reduction. Researchers analyzed spinal cord stimulation therapy for cervical and facial pain. The authors concluded that this spinal cord stimulation therapy is safe and effective for head and face pain indications including trigeminal neuralgia. This patients records document severe lifestyle limiting trigeminal neuralgia due to multiple sclerosis. The patient has been treated with most noninvasive and invasive treatment modalities including medication management and peripheral nerve blocks without significant durable relief. The patient has also undergone more invasive surgical therapy with balloon compression. The patients providers have recommended high cervical spinal cord stimulation in the epidural space to treat her trigeminal neuralgia at the cervicomedullary junction. Given the refractory nature of this patients trigeminal neuralgia secondary to multiple sclerosis, the requested percutaneous implantation of neurostimulator electrode array, epidural procedure is medically necessary for 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for hysterectomy.Hysterectomy is considered the definitive management for abnormal uterine bleeding and may also help with the treatment of pelvic pain. According to medical literature, a hysterectomy is performed to control bleeding. In this case, the patient has been worked up, with imaging showing evidence of uterine adenomyosis. First-line treatment options have been attempted, including medical management with hormone therapy. Although she has tolerated the Mirena IUD, her abnormal bleeding symptoms have persisted, and she continues to experience pelvic discomfort. Furthermore, she has a family history of ovarian cancer. For definitive management of her symptoms, hysterectomy is the appropriate next step. Thus, the requested hysterectomy is medically necessary for the treatment of the patients medical condition.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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the placement of perirectal spacers (SpaceOAR). A concern during prostate radiation is rectal toxicity due to exposure of the adjacent rectum to radiation. The SpaceOAR system deals with this issue by creating a space between the prostate and rectum, so that the rectum is out of the radiation treatment field. In a phase 3 study to examine absorbable hydrogel spacer use in prostate radiotherapy, Karsh and colleagues found that patients who underwent treatment with perirectal space experienced reduced rectal radiation, rectal toxicity and decreased rates of decline in bowel quality of life (QOL). The National Comprehensive Cancer Network (NCCN) guidelines for the management of prostate cancer endorse the use of perirectal spacers to improve sparing of the adjacent rectum. Therefore, the placement of perirectal spacers (SpaceOAR) was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the placement of perirectal spacers (SpaceOAR) 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 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Botox injections.The American Headache Society (AHS) recommends preventive treatment when attacks significantly interfere with patients daily routines despite acute treatment; a patient has four or more attacks per month; or a patient has contraindication to, failure, or overuse of acute treatment. Currently, Botox (onabotulinumtoxinA) is approved by the U.S. Food and Drug Administration for the treatment of chronic migraines. In 2016, the American Academy of Neurology (AAN) updated its 2008 guidelines on using botulinum neurotoxin for brain disorders. OnabotulinumtoxinA is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. According to the AAN guidelines, onabotulinumtoxinA is established as effective and should be offered to increase headache-free days. A 2018 review of the current evidence of onabotulinumtoxinA in the prevention of chronic migraine by a group of researchers noted that the totality of evidence from clinical trials and real-world studies indicates that onabotulinumtoxinA is an effective and generally well-tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. Additionally, researchers conducted a study that showed that patients were able to manage their chronic migraines with a combination of Botox and a calcitonin gene-related peptide (CGRP) inhibitor, improving 40% to 80% over their baselines. In this case, the patient has a history of chronic migraines and has not responded to oral preventive medications. Notes reflect that the patient has been taking a CGRP inhibitor (Ajovy). Based on the AHS statement, AAN guidelines and study noted above, the patient is a candidate for prophylactic treatment with botulinum toxin therapy. Therefore, the requested Botox injections are 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Monovisc injection to the left knee. 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 osteoarthritis of the left knee. She has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Monovisc injection to the left knee 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Otezla 10 mg/20 mg/30 mg titration pack  55 tablets for 28 days, then Otezla 30 mg twice daily. Findings:  The physician reviewer found that Otezla (apremilast) is a phosphodiesterase-4 (PDE4) inhibitor, which decreases PDE4 activity, which in turn reduces the inflammatory process thought to be associated with psoriasis and psoriatic arthritis. According to Nassim and colleagues, apremilast has shown therapeutic efficacy when the use of standardized treatments such as systemic corticosteroids or immunosuppressive agents have not been effective or practical or have caused excessive side effects. Otezla can be helpful in settings where traditional treatments do not work well enough. In this case, the patient has a history of plantar erosive lichen planus as well as oral/vulvovaginal erosive lichen planus being treated with immunosuppression and PUVA soaks. She has had to be on disability from her job due to her condition. Thus, the patient has severe disease. The patient has been refractory to traditional therapies, topical steroids and tacrolimus as well as more aggressive therapies, like IVIG. There is sufficient support for the requested medication in this clinical setting. Thus, the requested Otezla 10 mg/20 mg/30 mg titration pack  55 tablets for 28 days, then Otezla 30 mg twice daily is medically necessary for the treatment of the patients medical condition.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcatheter placement of intravascular stent(s), intracranial, including balloon angioplasty. The records reviewed document that this patient has a history of idiopathic intracranial hypertension. The intracranial hypertension was found to be due to stenosis of the venous sinus with a large arachnoid granulation. The provider has recommended stenting of the venous sinus. Intracranial hypertension has been found to be related to venous sinus stenosis and stenting has been successful for the treatment of a majority of patients in this clinical setting. Given this support, the requested transcatheter placement of intravascular stent(s), intracranial, including balloon angioplasty is medically necessary for 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 otolaryngology 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:  An enrollee has requested authorization and coverage for Ensure nutrition supplement shake.According to medical literature, lower protein intake was associated with increased risk of mobility limitation in community-dwelling, initially well-functioning older adults. Additionally, the study by researchers found that protein intakes of greater or equal to one gram per kilogram body weight per day may be optimal for maintaining physical function in older adults. Weight loss in older adults is multifactorial. The approach to undesirable weight loss includes lifting dietary restrictions, supplementing diets with nutrient dense food or adding milk powder/whey protein/egg whites or tofu to the food. Taking a daily multivitamin is also important. If these interventions are ineffective, a nutritional supplement can be considered. Nutritional supplementation can result in modest improvement in percentage weight gain. Additional treatment can be in the form of appetite stimulant medications. In this case, the documentation does not support that the patient has had significant weight loss or could not be treated with a soft or blended diet/supplement. There is no documentation to support that she is underweight or has any disorders that prevent her from chewing her food or swallowing solid foods. Additionally, there is no indication that she has met with a nutritionist or has been supplementing her own diet with high protein supplements or fats. Therefore, Ensure nutritional supplement shake is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested supplement 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 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 whole-body positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan (CPT 78816/HCPCS A9552). The National Comprehensive Cancer Network guidelines in oncology for occult primary do not support the use of routine PET scans for cancer surveillance. Rather, PET scans are typically used in patients with known or suspected cancer for staging and guiding diagnostic or therapeutic decision making. In this case, the patient is asymptomatic. In this clinical setting, the requested service is not medically indicated. Therefore, whole-body positron emission tomography (PET) with concurrently acquired CT scan (CPT 78816/HCPCS A9552) is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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 sub-specialty 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 authorization and coverage for Linzess 290 mcg. The U.S. Food and Drug Administration (FDA) has approved the use of Linzess for the treatment of patients with chronic idiopathic constipation. The current American Gastroenterological Association (AGA) guidelines for the treatment of constipation recommend the use of osmotic and then stimulant laxatives before advanced agents such as Linzess. This patients records document a history of chronic constipation, diverticulitis, and abdominal pain, as well as small bowel obstruction. Although the patient has constipation, the documentation does not report failure of safe, effective initially recommended over the counter laxative alternatives to support an indication for treatment with Linzess. Moreover, the U.S. Food and Drug Administration (FDA) approved prescribing information states that Linzess is contraindicated in patients with known or suspected mechanical gastrointestinal obstruction. In this case, the patient was reportedly admitted and treated for small bowel obstruction. For these reasons, the requested Linzess 290 mcg is 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 certification in 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.