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 magnetic resonance imaging (MRI) of breasts (CPT 77046). The American College of Radiology (ACR) recommends screening breast MRI in women at high risk for breast cancer on the basis of family history or genetic predisposition. The ACR appropriateness criteria for breast cancer screening categorizes women with 20% or greater lifetime risk of breast cancer as high-risk. For such women, breast MRI without and with intravenous  contrast is usually appropriate. Spick and colleagues found that short-term follow-up MRI at intervals of six, twelve, and 24 months of MRI-detected probably benign (BI-RADS 3) lesions remained a strong tool with which to detect suspicious lesions, and monitor interval changes in size, morphology, or enhancement that may be indicative of malignancy. In this case, the patients provider calculated her lifetime risk at 26%, placing her in the high-risk category. Therefore, MRI of breasts (CPT 77046) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the service at issue 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 service at issue was 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 diagnostic radiology 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 patient has been diagnosed with dyspareunia and vaginal atrophy. The patient reported persistent and worsening painful intercourse. The patient has been treated with vaginal estrogen two to three times per week, without improvement. The patient has requested authorization and coverage for Osphena. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Osphena is medically necessary for the treatment of the patients medical condition. The U.S. Food and Drug Administration (FDA), approved Osphena in 2013. The FDA noted, Osphena is an estrogen agonist/antagonist indicated for the treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy, due to menopause. Tan and colleagues reported, Oral, transdermal, or vaginal estrogen preparations are the most effective treatment options for vulvovaginal atrophy-related sexual dysfunction. Selective estrogen receptor modulators such as lasofoxifene and ospemifene showed a positive impact on vaginal tissue in postmenopausal women. In this case, the patient has been diagnosed with dyspareunia and vaginal atrophy. She has tried vaginal estrogen, without improvement. The medical evidence supports the requested medication in this clinical setting. Therefore, Osphena 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 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: The patient has requested authorization and coverage for Vyvanse 60 mg daily.The U.S. Food and Drug Administration had approved the use of Vyvanse (lisdexamfetamine dimesylate) for treatment of ADHD. Vyvanse is part of a class of long-acting agents known as prodrugs that do not rely on mechanical releases that may be affected by gastrointestinal factors, such as transit time and pH. Unlike other stimulant medications, prodrug absorption and conversion are not prone to food or drug interactions. Adler and colleagues found that among adults with ADHD and clinically significant executive function deficits, lisdexamfetamine dimesylate was associated with significant improvements in self-reported executive function ratings. In this case, the patient has been diagnosed with ADHD. He has been stable on Vyvanse, and it would be against the standard of care to stop this medication. Given that this patient is at risk of decompensation and functional decline without his current medication, Vyvanse is medically indicated for this patient. Therefore, Vyvanse 60 mg daily 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 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 Evenity (romosozumab-aqqg) monthly injections (J3111). Per evidenced-based guidelines, intravenous (IV) bisphosphonate therapy is recommended for the treatment of osteoporosis to decrease osteoporotic fractures in patients who are intolerant to oral bisphosphonates. Evenity is another treatment option for postmenopausal women at high-risk for osteoporotic fracture. However, current studies have reported an increased risk of serious adverse cardiovascular events with Evenity when compared to IV bisphosphonate therapy. This patients records document osteoporosis with a T-score of -3.7 in the spine. The patient was reportedly treated with Fosamax, which was discontinued due to gastrointestinal distress. The provider has recommended Evenity in lieu of IV bisphosphonates to avoid reduced efficacy of other agents such as Prolia, Forteo, and Evenity. The records provided for review do not report the patients current cardiovascular history to establish the risk associated with use of Evenity. Moreover, there is no documentation of a trial of IV bisphosphonate therapy. All told, the requested Evenity (romosozumab-aqqg) monthly injections (J3111) are 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 is board certified in internal medicine with subspecialty certification in rheumatology 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 enrollees parent has requested reimbursement and prospective authorization and coverage for neurofeedback therapy. This patient presents with a history of attention-deficit/hyperactivity disorder (ADHD), generalized anxiety disorder (GAD), and sensory processing disorder. The provider reports that some of the patient demonstrates some autistic features and symptoms of depression. His provider has recommended neurofeedback after the patient failed to improve with maximally dosed amantadine and occupational therapy. Neurofeedback is a specific form of biofeedback that involves electroencephalography (EEG) to improve brainwave activity, particularly in patients with anxiety disorder. In the peer-reviewed medical literature, Studies found that changes in mean abnormal anxiety were significantly higher in the neurofeedback group than in the control group. For the ADHD portion of this patients impairment, Researchers noted that based on the results and methodologies of published studies, this review concludes that (neurofeedback) for pediatric ADHD can be currently considered as probably efficacious. Based on this support, treatment with neurofeedback is appropriate to treat this patients behavioral health conditions. All told, the neurofeedback therapy twice per week was and 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 services at issue were and are 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 and are likely to be more beneficial for evaluation 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 psychiatry with subspecialty certification in child and adolescent psychiatry 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 parent of an enrollee has requested authorization and coverage for an In-Home Family Treatment (IIFT) program that includes video monitoring in the home setting, individual therapy in the office and home setting, and family therapy (with and without the enrollee) in the home setting.In this case, the patient has diagnoses of oppositional defiant disorder and major depressive disorder. The submitted documentation indicates that the patient has a history of significant anxiety and mood concerns that have contributed towards suicidal ideation and self-harm, which in turn have contributed towards two psychiatric hospitalizations and failed outpatient treatment. The submitted records reflect that the patient had an intake assessment that indicates that the patient is a good candidate for in home family therapy, with treatment goals of improving family relationships and teaching the patient to use emotion regulation and distress tolerance skills to reduce suicidal urges and reduce psychiatric hospitalizations to zero. Records indicate that less intensive behavioral interventions such as outpatient individual therapy, outpatient psychiatric care, and outpatient dialectical behavior therapy have been unsuccessful in reducing or eliminating the patients problem behaviors. In addition, clinical evaluation suggests that the patients clinical condition would benefit from the requested in home family therapy, which is designed specifically for complex children and adolescents to stabilize them in the home. Accordingly, the requested In-Home Family Treatment (IIFT) program including 24-hour video monitoring in the home setting and utilization of clips of negative interactions for therapeutic and family therapy purposes, one hour per week of individual therapy in the office setting (code 90837), one hour per week of individual therapy in the home setting (code 90837), one hour per week of family therapy with the patient present in the home setting (code 90847), and one hour per week of family therapy without the patient present in the home setting (code 90846), for approximately 6 to 9 months with a reduction in hours as the patients condition improves, is medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent 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: An enrollee has requested authorization and coverage for H.P. Acthar Gel 80 units daily for 10 days.The submitted documentation supports that the requested medication is medically necessary. In this case, the patient has relapsing remitting multiple sclerosis. The patient has acute exacerbation of disease with severe fatigue, balance impairment and weakness. It is reported to be difficult for the patient to go to an inpatient facility to receive IV steroids. The use of H.P. Acthar Gel is indicated under such conditions where the patient is not able to tolerate steroids or transport to an inpatient facility poses a barrier. Under these circumstances, the requested medication, H.P. Acthar Gel 80 units daily for 10 days, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's 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 brand name medication, Norditropin Flexpro 15 mg/1.5 mL (10 mg/mL) pen injector. Studies found that switching between different types of recombinant human growth hormone (rhGH) had no impact on efficacy or safety in children with growth hormone deficiency, and that various rhGH preparations were well tolerated. Current medical literature does not suggest that there is a medical benefit in using one brand over another to treat children with Prader-Willi syndrome. In this case, however, the patient has been successfully treated with brand Norditropin Flexpro. Given the equivalence of efficacy of recombinant growth formulations, and the history of successful use of this formulation, the brand name medication , Norditropin Flexpro 15 mg/1.5 mL (10 mg/mL) pen injector 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 pediatrics with sub-specialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperthermia treatments using ultrasound guided heat therapy (CPT codes 77605, 77427, and 77280). The provider has recommended hyperthermia. Based on the current medical literature, regional hyperthermia or combination with radiotherapy are not the standard of care for stage IV breast cancer. The standard therapy for stage IV breast cancer is some form of systemic therapy, usually chemotherapy. There is a lack of data supporting the addition of hyperthermia to the involved area, such as the lung or pleura. Therefore, hyperthermia treatments using ultrasound guided heat therapy (CPT codes 77605, 77427, and 77280) are 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 hyperthermia treatments using ultrasound guided heat therapy (CPT codes 77605, 77427, and 77280) 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. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical 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 reimbursement for monitored anesthesia care (MAC) provided during a colonoscopy. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the 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 authors recommended that, anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, 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. In this case, the patient underwent a routine screening colonoscopy. She did not have any significant heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. The patient was not morbidly obese. Although the patient reported a history of pain with colonoscopy which resulted in the procedure being discontinued, there was no detailed description of previous history of difficulties with anesthesia or sedation with past colonoscopies documented in the submitted records. The patient had an ASA classification score of 2 and had a Mallampati airway grade of 2. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the services at issue were not medically indicated. Therefore, monitored anesthesia care (MAC) provided during a colonoscopy was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 sub-specialty 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 parathyroid planar imaging scan (CPT 78070). The parathyroid glands are small endocrine glands in the neck that produce parathyroid hormone in order to regulate blood calcium levels. Hyperparathyroidism is overactivity of the parathyroid glands that can result in excess production of parathyroid hormone and lead to numerous complications. Whereas preoperative sestamibi-technetium 99m scintigraphy was previously an important prerequisite for successful targeted parathyroidectomy, single-photon emission computed tomography/computed tomography (SPECT) and concurrently acquired computed tomography (CT) fusion provides a three-dimensional functional image with advanced contrast resolution to greatly improve preoperative localization of parathyroid tumors. This patient presents with elevated serum calcium, hyperthyroidism, hypercholesterolemia, hypercalcemia, and elevated lipids. Her provider has recommended SPECT with CT fusion, or parathyroid planar imaging scan, to rule-out hyperparathyroidism. This patients symptoms, laboratory results, and clinical history support an indication for parathyroid planar imaging per current medical literature. For these reasons, the requested parathyroid planar imaging scan (CPT 78070) is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism 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.