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 hypnotherapy services. Currently, hypnotherapy is not recommended for the treatment of patients with bipolar disorder and/or insomnia. Small observational studies have reported that hypnotherapy may increase slow wave sleep. However, the available evidence for hypnotherapy is limited primarily because of the small number of studies and low methodological quality of the included studies. Overall, there is a lack of robust and well controlled studies to support the utility of hypnotherapy for insomnia. Chamine and colleagues evaluated the available studies using hypnotherapy for the treatment of patients with sleep problems and other comorbid conditions with sleep problems. The authors found that, The current evidence is limited because of few studies assessing populations with sleep complaints, small samples, and low methodological quality of the included studies. Similarly, Lam and colleagues reported that additional studies are needed to include larger sample sizes as well as improved study designs and methodologies. For these reasons, the requested hypnotherapy services are 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 requested hypnotherapy services 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for wheelchair accessory, power seat elevation system. Power seat elevation systems are utilized for transferring, reaching, and looking at objects in environments designed for ambulatory patients. Adjusting a patients height when performing these tasks may reduce the onset of pain and comorbidities. The records document that this patient has significant residual limb and phantom limb pain. The patient is limited in ability to perform activities of daily living. Specifically, the patient is having difficulty with wheelchair propulsion, which is likely due to the patients age and injury. On review of the available reports, the patient is not a good candidate for prosthetics. The requested power seat elevation system will enable the patient to view and reach high objects safely and perform transfers all in a manner likely to reduce the patients pain and comorbidities. Moreover, the requested power seat elevation system will help reduce the patients risk of falls. Given these findings, the requested wheelchair accessory, power seat elevation system is medically necessary for treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dosage escalation for the medication, Stelara 90 mg/mL subcutaneous injections to every four weeks. Current medical literature supports dose escalation of Stelara to 90 mg every four weeks in this case. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, Kopylov and colleagues observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient has disease symptoms consistent with active disease while taking Stelara every eight weeks. While a Stelara level of at least 4.5 ug/mL is associated with effective disease control, laboratory testing results reported a low Stelara level of 2.0 ug/mL. Continuation of dosing at every eight weeks or discontinuation of Stelara may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, dosage escalation for the medication, Stelara 90 mg/mL subcutaneous injections to every four weeks, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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 presents with malignant neoplasm of upper-outer quadrant of right female breast, estrogen receptor (ER) positive, progesterone receptor (PR) positive, human epidermal factor receptor 2 (HER2) negative infiltrating ductal carcinoma. The patients provider has recommended treatment with IORT. The safety and efficacy of IORT was recently analyzed in a phase 3 study during which 1,305 patients were randomized to receive IORT versus standard treatment with external beam radiation therapy (Orecchia, et al.). The authors reported a higher rate of recurrence in patients treated with IORT compared to those who received standard whole breast radiation. Specifically, at a median follow-up of 12.4 years, the recurrence rate was 11% with IORT versus 2% with whole breast radiation. In addition, the NCCN and American Brachytherapy Society do not recommend treatment with IORT outside of a clinical trial (Tom, et al.). Based on these findings, 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 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 reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an invasive coronary angiography. The American College of Cardiology (ACC) guidelines note that a coronary angiography is considered a Class I recommendation for patients with suspected ischemic heart disease when results of noninvasive testing indicate a high likelihood of severe coronary disease. In this case,  a stress echocardiogram demonstrated provokable wall motion abnormalities in multiple left ventricular segments. Based on criteria published by the American Society of Echocardiography, this is indicative of potential multi-vessel coronary artery disease. Therefore, an invasive coronary angiography is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested invasive coronary angiography 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 service 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease and is actively practicing. Physician reviewer 3 is board certified 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One hyaluronan injection in the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of beneficial response to viscosupplementation of the left knee and she has expressed interest in treatment with a repeated Synvisc One injection. In addition, the medical records document that the patient has failed treatment with cortisone injections and NSAIDs. Given these findings, the requested Synvisc One hyaluronan injection in the left knee 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 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 Dupixent 300 mg/2 mL. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with available topical therapies. Boguniewicz and colleagues defined moderate-to-severe atopic dermatitis as greater than 10% BSA involvement and/or involvement of highly visible areas or those important for function and significantly impaired quality of life. The records document that this patient has moderate-to-severe atopic dermatitis with almost 10% BSA involvement including involvement of the hands. The patients provider has recommended treatment with Dupixent, which is supported with the highest-quality trial evidence for safety and efficacy in patients with atopic dermatitis (Siegels, et al.). Systemic cyclosporine is contraindicated in patients with hypertension and kidney impairment and is not recommended for long-term use due to these toxicities. The patients provider noted that the patient has failed topical steroids with triamcinolone and clobetasol, as well as Protopic and Elidel. Based on this patients records and medical literature recommendations, the requested Dupixent 300 mg/2 mL is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 laparoscopic surgical ablation of uterine fibroids. The records document that this patient has a history of heavy menses and uterine fibroids. Per the imaging reports, the patient was determined to have at least six round uterine masses consistent with fibroids. The patients provider has recommended treatment with laparoscopic surgical ablation of uterine fibroids. As noted in the medical literature, the current surgical options for uterine preservation in the treatment of patients with uterine fibroids include hysteroscopic and/or abdominal myomectomy, uterine artery embolization, magnetic resonance imaging (MRI) guided focused ultrasound surgery, and radiofrequency ablation. Per the American College of Obstetricians and Gynecologists (ACOG) recommendations, Laparoscopic radiofrequency ablation can be considered as a minimally invasive treatment option for the management of symptomatic leiomyomas in patients who desire uterine preservation. Chudnoff and colleagues found that ablation was associated with a significant reduction in leiomyoma symptoms with no device-related adverse events and a low surgical reintervention rate through 12 months. The authors concluded that radiofrequency ablation of uterine fibroids is well tolerated with good symptom relief and improved quality of life. All told, the requested laparoscopic surgical ablation of uterine fibroids 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 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Synvisc One injections (CPT J7325) given as one injection (6 mL) to each 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 tried and failed other conservative treatments including cortisone injections, with relief lasting only a few days, and an exercise program. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc One injections (CPT J7325) given as one injection (6 mL) to each knee 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for arthroscopic left shoulder surgery to include arthroscopic rotator cuff repair and arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures. The available records indicate that this patient is being treated for left partial-thickness tear, left rotator cuff tendinopathy, and left subacromial bursitis. The patient reports having difficulty reaching overhead and to reach behind his back. The patients left shoulder examination revealed subtle scapulohumeral asynchrony as he elevated to the mid-range. The provider has recommended left shoulder arthroscopy with rotator cuff repair surgery. However, there is a lack of documentation of attempts at recent, reasonable, and comprehensive less invasive conservative care measures. In addition, there is a paucity of large-scale, long-term studies in the peer-reviewed medical literature demonstrating the safety and efficacy of arthroscopic shoulder surgery for treatment of this patient. McElvany and colleagues noted that, future clinical studies on the outcome of rotator cuff repair must report important data relating to each patients condition, the surgical technique, the outcome in terms of integrity, and the change in patient self-assessed comfort and function. Given these findings, the requested arthroscopic left shoulder surgery to include arthroscopic rotator cuff repair and arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone (Norco). This patients records document a history of osteoarthritis, hypertension, and gout flares. The patients condition has been managed by two providers who have recommended treatment with non-opioid and non-pharmacological treatments including dietary modification. These recommendations are consistent with the recommendations in the current medical literature. Kumar and colleagues noted that, Colchicine, nonsteroidal anti-inflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) should be considered as first-line agents for gout flare management. Richette and colleagues commented that, In patients with frequent flare and contraindications to colchicine, NSAIDs [non-steroidal anti-inflammatory drugs] and corticosteroids, an interleukin-1 blocker should be considered. Overall, narcotic analgesics have a limited role in the management of patients with gout flares. Based on the medical records for review and current medical literature, the requested hydrocodone (Norco) 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 anesthesiology with subspecialty certification in pain 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.