Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for left eye cataract surgery with monofocal lens replacement. In this case, the patients visual acuity is noted as 20/25, with trace changes in the lens. However, testing results show mild reduction of contrast sensitivity in the left eye and reduced visual acuity on brightness acuity testing. Overall, these results support the notion that the cataract in the left eye is contributing to the patients visual symptoms. Given the results of the glare testing, while the patient should be aware that the glare from the right eye will still be present when driving at night even after cataract surgery in the left eye, the requested service is medically indicated to improve the patients symptoms. Therefore, left eye cataract surgery with monofocal lens replacement 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for radiofrequency ablation (RFA) of thyroid nodule. The records provided for review document that this patient presented with a thyroid nodule. Fine needle aspiration (FNA) biopsy demonstrated results consistent with a benign nodule. The patient is noted to have symptoms including weight loss, palpitations, and hot flashes, as well as compressive symptoms such as pain and constriction in the neck. The patients provider has recommended treatment with RFA. Subclinical hyperthyroidism is defined by a low or undetectable serum thyroid-stimulating hormone level, with normal free thyroxine and total or free triiodothyronine levels. As in this patients circumstance, the autonomously functioning thyroid nodule, if untreated, it can lead to potential health risks and impaired quality of life (Donangelo and Suh). Since RFA is less invasive than surgery, the procedure has been gaining popularity for treatment of thyroid nodules. Published studies suggest that RFA has an excellent safety profile compared to existing management strategies (Muhammad, et al.). In addition, recent data suggest that RFA has good efficacy and safety in the treatment of autonomously functioning thyroid nodules (Kim, et al.). Given this support, the requested RFA of thyroid nodule 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 RFA of thyroid nodule 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 services are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for back surgery (L4 through S1 anterior lumbar instrumented interbody fusion and a posterior wide decompressive laminectomy, surgical reduction of spondylolisthesis and instrumented fusion from L4 through S1). Findings:  The physician reviewer found that  The records provided for review document that this patient has low back pain with radiation and instability. The records document that the patient has failed conservative care with physical therapy, epidural steroid injections, and radiofrequency ablation. The patients provider has recommended L4 through S1 anterior lumbar instrumented interbody fusion and a posterior wide decompressive laminectomy, surgical reduction of spondylolisthesis and instrumented fusion from L4 through S1. Reid and colleagues found statistically significant improvement in functional outcomes after lumbar fusion in patients with chronic low back pain with radiation. The authors reported that, Lumbar fusion is an accepted and effective technique for the treatment of lumbar degenerative disease. The authors noted that candidates for lumbar fusion include patients who have degenerative changes and have failed conservative care. Hedlund and colleagues reported that the benefits of lumbar fusion are long-term, and the significant improvement compared to stand treatment persists for at least 12.8 years. Given these findings, the requested back surgery (L4 through S1 anterior lumbar instrumented interbody fusion and a posterior wide decompressive laminectomy, surgical reduction of spondylolisthesis and instrumented fusion from L4 through S1) 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 repair of nasal vestibular stenosis, with the approved septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft, and/or bilateral submucous resection of inferior turbinate, partial or complete. Based on available clinical documentation, the requested nasal vestibular stenosis repair, septoplasty, and turbinate reduction is medically necessary to adequately treat this patients intranasal valve stenosis turbinate hypertrophy. In the peer-reviewed medical literature, van Egmond and colleagues published a randomized controlled trial comparing surgery to non-surgical modalities for the treatment of patients with nasal obstruction with a deviated nasal septum. The authors concluded that septoplasty was more effective than non-surgical management in improving objective and subjective measures at 24-month follow-up. Additionally, the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) clinical practice guidelines states that septorhinoplasty can improve the nasal airway in well selected patients, as in this patients clinical setting (Ishii, et al.). Given this support, the requested repair of nasal vestibular stenosis, with the approved septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft, and bilateral submucous resection of inferior turbinate, partial or complete are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) four days/week, for ten weeks. McClintock and colleagues note that there is an abundance of data pertaining to the safety and efficacy of TMS for individuals with major depressive disorder. The American Psychiatric Association (APA) guidelines for the treatment of major depressive disorder recognize the safety and efficacy of TMS in the treatment of patients with a prolonged course of depression. In this case, the records document treatment refractory depression, as the patient has failed three antidepressant trials in addition to psychotherapy. The provider has recommended treatment with TMS. The records noted that the patient made significant gains with previous TMS therapy. However, the patient now is again suffering from an episode of recurrent, severe major depressive disorder, with passive suicidal ideation. Given that current medical literature supports the use of TMS for the treatment of refractory depression, the requested services are medically indicated. In this patients case, TMS is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, TMS four days/week, for ten weeks, 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy (PBRT) with high dose 28 fractions. The requested PBRT is supported as medically necessary for treatment of this patient based on the current medical literature and guidelines given her BRCA mutation positivity. PBRT is the most appropriate radiation modality in this patients clinical setting since she has a genetic mutation that increases her risk for radiation-induced side effects, including secondary malignancy. PBRT can effectively minimize the volume of normal tissue exposed to ionizing radiation, thereby limiting the patients risk for serious high-grade morbidity. Per the American College of Radiology (ACR) and ASTRO practice parameters PBRT may permit improved therapeutic ratios with lower doses to sensitive normal structures and greater dose to target tumor tissues. PBRT is supported by the American Society for Radiation Oncology (ASTRO) recommendations for treatment of this patient since she is BRCA mutation positive. Given these findings, the requested PBRT with high dose in 28 fractions 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 radiation oncology 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 referral to an eye movement desensitization and reprocessing (EMDR) specialist. Findings:  The physician reviewer found that EMDR is specifically indicated for the treatment of patients with post-traumatic stress disorder (PTSD). Based on the available documentation, this patients presentation does not support a diagnosis of PTSD. In addition, there is a lack of documentation of symptoms consistent with PTSD. Bereavement is distressing, particularly that after a childs death. However, this is not considered an exposure to an actual or threatened death, injury or violence, which is required for a PTSD diagnosis per the American Psychiatric Association (APA). Tol and colleagues noted that, For adults, adolescents, and children with PTSD, recommended treatments include individual or group CBT-T [cognitive behavior therapy with a trauma focus], eye movement desensitization reprocessing (EMDR) and, in adults, stress management. The patient would benefit from psychological support including grief support group therapy to aid in grieving the loss of her son. However, there is a lack of indication for EMDR therapy. The records do not report that EMDR has been recommended by any of the patients treatment providers. Moreover, the requested referral to a specialist in EMDR is not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the requested referral to an EMDR specialist 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 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 reimbursement for  monitored anesthesia care (MAC) services provided during an endoscope procedure. The current guidelines for sedation and anesthesia in gastrointestinal endoscopy concluded that that use of a combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The guidelines further state that, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. Researchers cautioned that their findings suggest that use of anesthesia service was associated with a 13% increase in the risk of any complication within 30 days. In this case, the patient presented for a routine endoscopy. The patient does not have any documentation of significant heart, lung, kidney, or liver disease. There is a lack of documentation of a history of alcohol or substance abuse, previous history of difficulties with anesthesia, or sedation with past colonoscopies documented in the records provided for review. The provider assessed the patient to have an airway classification score of 2 and there was no evidence that he presented with a difficult airway. For these reasons, the MAC services provided during an endoscope procedure were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg. The U.S. Food and Drug Administration (FDA) approves the use of Xifaxan 550 mg three times daily for 14 days for the treatment of IBS-D. The American College of Gastroenterology (ACG) guidelines on the management of IBS recommend rifaximin to treat global IBS with diarrhea symptoms. Schoenfeld and colleagues report that rifaximin has been proven as safe and effective in randomized placebo-controlled trials for IBS-D. Lembo and colleagues report in a phase 3, randomized, double-blind, placebo-controlled trial with over 1,000 patients that Xifaxan proved effective, resulting in significant symptom improvement in IBS. In this case, the patient has a diagnosis of IBS-D, along with SIBO. According to Gatta and Scarpignato, rifaximin (brand name Xifaxan) treatment is effective and safe for the treatment of SIBO. In a prospective trial of patients with IBS and a positive breath test for SIBO, Moraru and colleagues reported that rifaximin effectively normalized the  glucose hydrogen breath test, and reduced IBS symptoms. Given that current medical literature supports the use of Xifaxan for the treatment of SIBO in the setting of IBS-D, the requested medication is medically indicated. Therefore, Xifaxan 550 mg 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Ubrelvy 100 mg tablets (10 tablets per 30 days). 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 Ubrelvy as a calcitonin gene-related peptide (CGRP) receptor antagonist indicated for the acute treatment of migraine with or without aura in adults, with the recommended dosage being 50 mg or 100 mg taken orally, as needed. In two randomized, double-blind, placebo-controlled trials evaluating the efficacy, safety, and side-effect profile of Ubrelvy for the acute treatment of migraine, Dodick and colleagues report that the percentage of patients achieving headache pain freedom two hours post dose was significantly greater among patients receiving Ubrelvy compared to those receiving placebo. 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 medications. Given that Ubrelvy 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, Ubrelvy 100 mg tablets (10 tablets per 30 days) are 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stretta procedure. This patient presents with a history of GERD and a hiatal hernia as well as erosive esophagitis. There are several contraindications to Stretta including hiatal hernia larger than 2 cm, achalasia or incomplete LES relaxation in response to swallow. This patients hernia is documented to be 3-4 cm, which is considered a contraindication for the Stretta procedure. There have been multiple studies evaluating the short- and long-term efficacy of the Stretta procedure. Lee and Chang discussed the mechanism of Stretta, which utilizes radiofrequency energy to the lower esophageal sphincter (LES) and gastric cardia to improve symptoms of gastroesophageal reflux. Stretta has been shown to be effective at improving heartburn scores and quality of life in multiple randomized, controlled trials as well as non-randomized prospective trials for up to 12 months (Arts, et al.). However, a recent meta-analysis on the safety and efficacy of Stretta demonstrated no benefit over placebo (Lipka, et al.). Moreover, the ACG guidelines do not endorse treatment with Stretta for patients in the management of GERD (Katz, et al.). All told, the requested Stretta procedure 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 Stretta procedure 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 internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in gastroenterology 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.