Persius/hicric huggingface dataset:
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 a cold therapy machine. Given the information provided, the patient underwent an arthroscopic posterior cruciate ligament (PCL) reconstruction and meniscal repair. As part of her post-operative regimen, the provider recommended a cold therapy machine. Per the current peer-reviewed medical literature, cold therapy machines can help with immediate post-operative pain. However, there is minimal evidence that a cold therapy machine decreases narcotic usage or leads to a better functional outcome. Overall, standard ice packs have been shown to produce the same clinical results in the long-term. Accordingly, the requested cold therapy machine is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Two of the three physician reviewers found the requested cold therapy machine 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 device is 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 orthopedic surgery with expertise in pediatric 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: Medical Necessity
Decision: Overturned Decision of Health Plan

 The patient has requested authorization and coverage for Gilenya capsules. Gilenya is a U.S. Food and Drug Administration (FDA) approved therapy for the treatment of RRMS. Gilenya was the first in class disease modifying treatment in multiple sclerosis that acts as sphingosine-1-phosphate receptor agonist. Since approval in 2010, there is a growing experience with Gilenya use in clinical practice (Ziemssen, et al.). This patient has been stable on ocrelizumab, but has developed side effects. The provider has recommended a change in therapy to avoid treatment related complications. Given these findings, the requested Gilenya capsules are 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 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

The patients parent has requested authorization and coverage for onabotulinumtoxinA (Botox) injections. Based on the available documentation and current medical literature, the requested Botox injections are medically necessary for treatment of this patients medical condition. The patient is already taking Prozac as an antidepressant, which is a relative contraindication to the addition of amitriptyline, a tricyclic antidepressant. Topiramate has the potential to worsen her depressive symptoms. Botox is a potent muscle relaxant, which has been found to have analgesic effects in patients with a variety of pain syndromes. Data from clinical trials have confirmed the efficacy, safety, and tolerability of Botox in the prophylactic treatment of chronic migraine in adults. The U.S. Food and Drug Administration approved Botox for the treatment of chronic migraine in 2010. In addition, several studies have reported that Botox injections are also effective for chronic daily headache and migraine in children and adolescents (Ahmed, et al.; Kabbouche, et al.; Herd, et al.). This patient has failed treatment with acute abortive medications including sumatriptan and ibuprofen and has required multiple emergency room visits for migraine, receiving intravenous fluids and Toradol. Given the patients history of head trauma with concussive symptoms and the presence of chronic daily headache and chronic migraine, the requested Botox injections are 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 neurology with special qualification in child 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

The enrollee is requesting authorization and coverage for a custom foot brace (HCPCS codes L1951 and L2820). The enrollee has a history of diabetes. She was evaluated by her podiatrist due to complaints of bilateral leg numbness. She reported difficulty walking and  picking up her legs. The patient described symptoms of burning, tingling, and numbness at rest that have persisted for ten years. The podiatrist prescribed a custom dorsiflexed assist ankle foot orthosis (AFO) for her.  The Certified Prosthetist Orthotist (CPO) describes the enrollee as having a history of drop foot resulting from diabetes mellitus. She had not worn an orthosis previously. She requires a device that can hold up to her weight, ambulation, and activities of daily living. From assessing the enrollee and her gait pattern, the orthotist believes the Townsend Spry step spiral style carbon fiber ankle-foot orthotic (AFO) is the most clinically appropriate prefabricated AFO choice for her. A thermoplastic leaf spring AFO is inappropriate for this enrollee due to the deforming forces present during ambulation. The enrollees documented lower extremity musculoskeletal exam revealed 2/5 inversion and eversion bilaterally, and 0/5 dorsiflexion and plantarflexion bilaterally.  The physician reviewer found that her toes catch; causing her to trip and fall.  This has been going on for approximately 10 years and no conservative measures have helped.  The enrollee denies any orthotic or bracing treatments in the past. The podiatrist wrote an order for a dorsiflexed assisted custom AFO.  The CPO performed a detailed gait exam and muscle testing, which revealed left ankle weakness. The enrollee admitted to 23 falls in a three-month time span. The CPO trialed different types of ankle-foot orthosis (AFO) braces and determined a carbon fiber leaf spring AFO would result in decreased falls for the enrollee, while allowing her the most natural gait possible. The patients weight was a factor in the decision to proceed with this type of device.  A study showed both prefabricated and custom AFOs improved gait velocity, cadence, step length, and stride length in individuals with acute CVA. Individuals preference was for the custom-made plastic AFO over the prefabricated carbon AFO. Individuals felt more balanced and safe with the custom brace. Because documentation notes a failure of gait improvement in this enrollee with the different trials of prefabricated AFO braces, the custom AFO brace is necessary for her.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

 The enrollee is requesting authorization and coverage for the medication Epclusa, 400-100mg, for 12 weeks. The enrollee has hepatitis C virus (HCV), treatment naive, with elastography showing stage F2 (moderate) fibrosis. His HCV ribonucleic acid (RNA) was insufficient to obtain genotype. His gastroenterologist has requested authorization of Epclusa, 400-100mg, for 12 weeks. He states chronic HCV, even in those with limited liver damage, is linked to a higher likelihood of a wide array of health issues; such as cardiovascular disease, kidney disease and type-2 diabetes. Improving his quality of life is also critical; regardless of fibrosis score. Epclusa is the optimal treatment option for this enrollee. His provider notes the enrollee is no longer on a proton pump inhibitor (PPI) and therefore has no contraindications. The enrollee has Hepatitis C, fibrosis stage F2. The HCV RNA load was mildly elevated, but not high enough to obtain a genotype. Professional societies have issued guidelines for the treatment of Hepatitis C. It is the position of these societies that all those with chronic Hepatitis C should be treated unless they have a limited life expectancy. The physician reviewer found that  Epclusa has an overall cure rate of 98%. The enrollees viral load was still elevated and the enrollee already has a fibrosis score of F2. He should receive treatment that is active against all genotypes. Epclusa fulfills this requirement. It is therefore a medically necessary treatment.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Gene Assay testing.Findings:  Three physician reviewers found that this patient had an early stage melanoma. National Comprehensive Cancer Network (NCCN) guidelines state that while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. In addition, there are no definitive data regarding the use of gene expression profiling for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Accordingly, the DecisionDx-Melanoma Gene Assay testing services were not likely to have been more beneficial than any available standard treatment for the patients medical condition.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any available standard treatment for the patients medical condition. 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Tramadol tablets,. In this case, the patient has chronic pain and lumbar radiculopathy that was aggravated in a recent motor vehicle accident. Physical examination revealed anterior thigh numbness suggestive of lumbar radiculopathy. The provider has discontinued Soma and started the patient on Cymbalta along with a course of physical therapy and weight loss program. This treatment regimen is consistent with the current guidelines regarding a multi-modal pain management plan. In addition, the provider recommended Tramadol, which is a less potent opioid than Norco, which was part of the patients prior treatment regimen. The requested dose of Tramadol twice daily is the morphine equivalent of 10 mg, which is below the recommended threshold for low dose opioid therapy. All told, the requested Tramadol, 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 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

The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). Leggett and colleagues found that the available data on the use of repetitive TMS (rTMS) for adults with treatment resistant depression suggests that rTMS is approximately twice as effective as a sham procedure. Richieri and colleagues reported that maintenance TMS was associated with a significantly lower relapse rate in patients with pharmacoresistant depression in routine practice among responders. The clinical information indicates that this patient has pharmacoresistant depression. He achieved remission with TMS, but he has relapsed with symptoms of depression. The patient has experienced a return of depression symptoms and is having difficulty with vomiting which makes oral antidepressant medications difficult and likely ineffective. Since the guidelines have not specified an ideal number of TMS sessions, and patients respond differently to TMS, the number of sessions should focus on the individual patient. This patient has been intolerant to medical therapies yet he demonstrated prior success with TMS. Given these findings, the requested TMS 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

The patient has requested authorization and coverage for Amitiza. The records provided for review document that this patient has a history of chronic constipation. The provider reports that the patient has failed treatment with fiber as well as multiple laxatives, including magnesium hydroxide, which is an osmotic laxative. The American Gastroenterological Association (AGA) states that once conventional laxatives have failed, providers should consider advanced agents such as Linzess or Amitiza (Bharucha, et al.). In this case, multiple conventional laxatives were not effective, as well as Linzess, which is an advanced agent. Amitiza at the dose approved for chronic constipation, twice daily, was completely effective for the treatment of this patients constipation (Lacy, et al.; Wilson and Schey). For these reasons, Amitiza twice daily is medically necessary for the treatment of the patients chronic constipation. 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services, such as RTC level of care. For dimension 1, intoxication and withdrawal potential, the patient was noted to be withdrawing from multiple substances on admission. For dimension 2, biomedical issues, the patient needs to achieve and maintain sobriety in order to complete her hepatitis C treatment. Dimension 3 evaluates a patients emotional, behavioral, and cognitive issues. The records document comorbid PTSD and major depressive disorder requiring treatment. Dimension 4 addresses a patients readiness to change. This patient still requires redirection to address her behaviors that lead to isolation which results in substance use. For dimension 5, relapse and continued use problem potential, the patient has a history of multiple relapse and readmissions in large part due to her self-medicating her stress. She has been assessed to be in imminent danger to herself and relapse if discharged from the structure of the RTC. Dimension 6 focuses on a patients recovery environment. This patients records report that she has no support other than her mother and spouse. Based on these findings, the patient requires safe and stable living environment in order to develop her recovery skills. Given the severity of the patients illness, RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 with expertise in addiction 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for proton beam radiation therapy. The records provided for review demonstrate that this patient presents with a history of meningioma with recurrence over the right optic nerve. The use of proton radiation for treatment of this patients meningioma is not supported as superior per the current peer-reviewed medical literature. The standard of care in this clinical setting remains photon-based radiation therapy. A course of photon-based intensity modulated radiation therapy (IMRT) would provide this patient with acceptable risk to the surrounding normal critical structures. Although proton radiation has the ability to reduce low dose exposure to surrounding normal critical neuroendocrine structures, this low dose sparing has not been correlated with an improvement in clinical outcomes. Additionally, some studies report excessive toxicity with the use of proton beam radiation (Vaphiades). All told, the requested proton beam radiation therapy is 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 that the requested proton beam radiation therapy 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 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: The patient has requested reimbursement for anesthesia (CPT code 00731) administered during the endoscopy procedure received. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether anesthesia (CPT code 00731) administered during the endoscopy was medically necessary for the treatment of the patients medication condition. The American Society for Gastrointestinal Endoscopy (ASGE) Guidelines for sedation and anesthesia in gastrointestinal (GI) endoscopy state the following: We recommend 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. It was also stated that endoscopists use propofol-based sedation (endoscopist-directed or anesthesia-provider administered) when it is expected to improve patient safety, comfort, procedural efficiency, and/or successful procedure completion. Use of propofol in endoscopy procedures is associated with better patient cooperation, shorter recovery periods, higher post-sedation recovery scores, and better sedation than traditional sedation. In this case, the patient had no significant medical history. Her airway score was graded as Mallampati class one. The provider began the EGD procedure under a combination of local anesthetic spray and moderate sedation using fentanyl and Versed. The patient did not tolerate this level of sedation.  In order to complete the procedure safely, the depth of anesthesia was converted to deep sedation with propofol, and the procedure was subsequently completed successfully. The medical evidence supports the services at issue in this clinical setting. Therefore, anesthesia (CPT code 00731) administered during the endoscopy procedure that she received was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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.