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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation therapy (PBRT) initiated on 3/03/21 and forward for a total of 39 treatments.At issue is whether the PBRT initiated on 3/03/21 and forward for a total of 39 treatments was and/or are medically necessary to treat the patients medical condition.Currently, there is insufficient clinical data to discern whether treatment with proton beam therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Researchers performed a multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer. The authors compared groups receiving hypofractionated proton beam therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. A position statement released by the American Society of Radiation Oncology (ASTRO) stated, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed. Thus, the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity modulated radiation therapy technique. In conclusion, PBRT initiated on 3/03/21 and forward for a total of 39 treatments was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rytary. The U.S. Food and Drug Administration (FDA) approves the use of Rytary (generic name carbidopa and levodopa) for the treatment of Parkinsons disease. Hauser notes that levodopa remains the most effective medication to treat Parkinson's disease, and that extended-release carbidopa-levodopa is designed to achieve rapid absorption and onset of clinical benefit and to provide sustained therapeutic levodopa levels and duration of clinical benefit. The author further noted that extended-release carbidopa-levodopa was demonstrated to be efficacious in early Parkinsons disease compared with placebo, and in moderate-to-advanced Parkinsons disease, it provided more sustained clinical benefit with fewer dose administrations than carbidopa-levodopa immediate release. In this case, the patient has a diagnosis of Parkinsons disease and has tried and failed alternative therapies. Given that current medical literature supports Rytary as an effective and well-tolerated medication for Parkinsons disease, the requested medication is medically indicated. Therefore, Rytary 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for tolerance induction program (TIP). The Food Allergy Practice Parameters state that, Although immunotherapeutic approaches, such as oral immunotherapy, in clinical trials show promise in treating food allergy, they are not ready for implementation in clinical practice at the present time because of inadequate evidence for therapeutic benefit over risks of therapy . The standard of care is strict avoidance of peanut. Epinephrine auto injectors are used for the treatment of reactions due to accidental ingestions. The U.S. Food and Drug Administration (FDA) recently approved peanut allergen oral immunotherapy powder. However, data has shown that patients may have severe reactions, even on maintenance doses. Wasserman and colleagues concluded that, Peanut oral immunotherapy carries a risk of systemic reactions. Due to difficulty determining the effects of oral immunotherapy, significant adverse reactions to doses and potential of developing eosinophilic esophagitis, the world experts on food allergy agree that food oral immunotherapy should remain limited to clinical research settings. In this case, the request is for tolerance induction program (TIP) or sustained unresponsiveness. The goal of the TIP is to administer higher doses to allow for addition to the diet. The plan is to also add other foods for which there are no standardized protocols. The guidelines continue to recommend allergen avoidance but allow for oral immunotherapy and now there is FDA approved medication for peanut oral immunotherapy. There is a lack of recommendations, national guidelines or large randomized controlled trials to support an indication for TIP over standard avoidance and use of epinephrine. All told, the requested TIP 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 TIP 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 internal medicine with subspecialty certification in allergy and  immunology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of the Inspire device. The Inspire hypoglossal nerve stimulator is approved by the U.S. Food and Drug Administration (FDA) for patients with moderate to severe obstructive sleep apnea (OSA) treatment with an apnea/hypopnea index (AHI) of 15 episodes or more per hour and a BMI less than 35 kg/m2. Hypoglossal nerve stimulator implantation is considered the current standard of care for patients who fail continuous positive airway pressure (CPAP) treatment, as in this patients clinical setting. Hypoglossal nerve stimulator showed significant improvement in treating patients with moderate to severe OSA with improved symptoms and decreased long-term complications from OSA. This patient with severe OSA was found to have an AHI average of 37.1 events per hour. His BMI was documented to be less than 30 kg/m2. As the patient has failed treatment with CPAP therapy as documented in his records, the hypoglossal nerve stimulator implantation is an appropriate treatment modality. All told, the requested implantation of the Inspire device is 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 implantation of the Inspire device 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. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 2 is board certified in otolaryngology with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 3 is board certified in otolaryngology 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 Dynasplint for the right elbow. This patient is being treated for stiffness, or contracture, of the right elbow. He underwent right elbow reconstruction and right elbow excision of heterotopic ossification contracture. Occupational therapy notes conclude that he has plateaued with forearm supination despite active therapy. The patients supination fluctuated from 40-50 degrees for three weeks and he has not moved greater than 50 degrees of supination. Current, published peer-reviewed medical literature supports the use of a Dynasplint dynamic splint with noted improvement with range of motion with use of the device. Lindenhovius and colleagues concluded that post-traumatic elbow stiffness can improve with exercises and dynamic or static splinting over a period of six months to one year. Veltman and colleagues reviewed eight randomized and cohort studies and found evidence of improvement with either static-progressive or dynamic splinting for post-traumatic elbow stiffness regardless of specific etiology. For these reasons, the requested Dynasplint for the right elbow is 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 Dynasplint for the right elbow 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 device 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for authorization and coverage for a Nalu Neurostimulation System. In a systematic review of 14 randomized control trials, researchers reported moderate to strong evidence supporting the use of peripheral nerve stimulation (PNS) to treat pain, including in the sural, superficial peroneal, and lateral femoral cutaneous nerves. In a review of the bioelectrical implications of stimulation of the PNS for chronic pain conditions, researchers noted that PNS utilization produced consistently high success rates in achieving pain relief in well selected patients when delivered by skilled clinicians. In this case, the patient has a history of chronic left shoulder pain and has failed conservative treatment, including physical therapy, chiropractic care, behavior modification, transcutaneous electrical nerve stimulation (TENS) therapy and psychiatry. Visit notes reported that the patient had failed medication management with nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, along with interventions such as suprascapular nerve blocks. The records noted that the patient reported success with a PNS trial. In this clinical setting, the current medical literature supports the use of PNS as superior to conservative therapy, which has already been tried and failed. Therefore, a Nalu Neurostimulation System is 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 Nalu Neurostimulation System 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 equipment 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 reviewers 1 and 3 are board certified anesthesiology with sub-specialty certification in pain medicine and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine 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 Vumerity. The records document that this patient presents with multiple sclerosis that has partially responded to prior therapies. The provider reports that two other medications initially provided symptomatic improvement, but this was followed by intolerable adverse effects. The patient was switched to Vumerity with good response and no side effects. Per the American Academy of Neurology (AAN) practice guideline recommendations, switching the patient to Vumerity, which is a different disease-modifying therapy, was appropriate. The U.S. Food and Drug Administration (FDA) has approved Vumerity as a disease-modifying therapy for patients with relapsing forms of multiple sclerosis, including clinically isolated syndrome, relapsing-remitting multiple sclerosis, and active secondary progressive multiple sclerosis. Given these findings, the requested Vumerity 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 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: An enrollee has requested reimbursement for a Botox injection. Medical literature supports the use of botulinum-A toxin in adult patients with Over Active Bladder (OAB) if the following criteria are met: there has been conservative therapy with appropriately dosed, prescription anticholinergic medications that have failed or are contraindicated; documented failure of behavioral therapy; no acute urinary retention; and no acute urinary tract infection. In this case, the patient had OAB symptoms unrelieved by Percutaneous Tibial Nerve Stimulation (PTNS). Additionally, the patient had undergone conservative therapy with Myrbetriq 10 mg and VESIcare 5 mg. The documentation also shows  the patient had failed behavioral therapy. Given the patients plans on pregnancy, alternative medications are contraindicated. Thus, the Botox injection was medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the service at issue was 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 urology 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 artificial disc arthroplasty (CPT code 22857  total disc arthroplasty (artificial disc), anterior approach). The U.S. Food and Drug Administration (FDA) approval for the ProDisc-L total disc replacement states that the device is indicated for patients with spinal arthroplasty who are skeletally mature, have degenerative disc disease at one to two levels in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level, and have had no pain relief after at least six months of non-surgical treatment. FDA exclusions include active systemic or site infection, osteopenia or osteoporosis, bony lumbar spinal stenosis, isolated radicular compression syndromes especially due to disc herniation, and pars defect. Buttner-Janz and colleagues noted with respect to safety, there was good agreement in the medical literature to exclude patients with osteopenia or fracture. Zigler and Delamarter concluded that patients undergoing both ProDisc-L total disc replacement and circumferential arthrodesis for the treatment of single-level degenerative disc disease maintained significant improvement during the five-year follow-up. This patient is being treated for L5-S1 discopathy, spondylotic stenosis. She presents with severe low back pain radiating to the right leg and left lower extremity paresthesias. She reports that her persistent and intractable low back pain negatively affects her ability to get out of bed. Her range of motion has become restricted as her chronic pain has worsened. Documentation reveals that she has failed conservative treatment for six months with continued pain and symptoms. However, there is evidence of multi-level disc degeneration at the thoracolumbar region. These highly degenerative disc levels represent significant unaddressed plausible pain generators in this patient. There are also clinical and imaging findings of radicular pain syndrome due to recurrent disc herniation, which is an FDA associated contraindication. For these reasons, the requested artificial disc arthroplasty (CPT code 22857  total disc arthroplasty (artificial disc), anterior approach) is not medically necessary for 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 Taltz. Psoriasis is often a chronic condition with periods of remissions and exacerbations. Indications for a biologic agent such as Taltz requires current documentation of moderate-to-severe psoriasis or active psoriatic arthritis. The records provided for review do not support a current indication for treatment with Taltz. The patients last documented evaluation was in 2019 for psoriasis of the skin. There is a lack of report of any exacerbations, treatments, and/or physical examinations for 2020 or 2021. Per the joint American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF), there are many factors that must be considered by a provider prior to recommending treatment with Taltz and regular follow-up with the treating provider is essential. All told, the requested Taltz 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 dermatology with subspecialty certification in dermatopathology 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.