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 proton beam radiation therapy with gel spacer device. Current evidence does not endorse the use of proton therapy over photon techniques utilizing intensity modulated radiation therapy (IMRT). In a comparison of proton radiotherapy versus IMRT in the treatment of prostate cancer, Yu and colleagues found no difference in toxicity one year post-treatment. Hoppe and colleagues reported no differences in patient-reported quality-of-life outcomes between patients treated with proton therapy versus patients treated with IMRT for prostate cancer. While Karsh and colleagues have reported some benefits in the use of a hydrogel spacer in reducing the rectal dose, toxicity, and quality-of-life declines after image guided IMRT, there is a lack of literature supporting the use of gel spacers in conjunction with proton therapy. Therefore, proton beam radiation therapy with gel spacer device is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested proton beam radiation therapy with gel spacer device 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 service 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast reduction surgery. Cabral and colleagues noted that patients with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction. This patient presents with complaints of back pain and her bra straps digging into her shoulders due to her heavy breasts. The records provided for review do not document shoulder grooving on physical examination, and shoulder grooving is not visible in the photographs received for review. In addition, the records do not document chronic neck or back pain due to weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. There is no report of the proposed resection of breast weight. Per the American Society for Plastic Surgeons (ASPS), at least two documented quality of life signs are needed to support an indication for breast reduction surgery. In the absence of this documentation, the requested breast reduction surgery is not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Based on the available documentation, the patient complains of back pain from pressure of her bra straps. The patient has comorbid scleroderma and fibromyalgia that required multiple pain medications. There is a lack of evidence that the patients pain or function is attributed to her breasts and that her function would be improved with breast reduction surgery. Moreover, based on the available documentation and photographs, the appearance of the patient is not abnormal. The requested surgery would not provide a more than minimal improvement in the appearance of the patient. For these reasons, the requested breast reduction surgery is not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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 a sumatriptan injector pen dosed at 6 mg two (2) times a day (60 pens per 30-day supply). The U.S. Food and Drug Administration (FDA) approves the use of sumatriptan injections for the treatment of cluster headache episodes. In this case, the patient has been diagnosed with cluster headaches and has been approved for sumatriptan vials. Given that an autoinjector reduces the risk of overdosing and allows the patient to carry the medication with her outside of the home, the requested medication is medically indicated. Additionally, two shots per day is also appropriate. In terms of safety, the maximum is dose is 12 mg in 24 hours. Therefore, a sumatriptan injector pen dosed at 6 mg two (2) times a day (60 pens per 30-day supply) 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right shoulder and right shoulder arthroscopy, open reduction with internal fixation (ORIF) surgery. The American College of Radiology (ACR) guidelines do not recommend MRI for the evaluation of traumatic shoulder pain when radiographs show humeral head or neck fracture. Steinhaus and colleagues discussed the complex treatment of displaced proximal humerus fractures, as its success is predicated on multiple factors. The authors noted that the majority of proximal humerus fractures may be treated non-operatively, and studies have not established which patients will benefit from surgical management. Howard and colleagues evaluated three randomized controlled trials and concluded that the available data have not demonstrated a difference in patient-centered outcomes when comparing non-operative treatment with ORIF surgery. This patient presents with a history of right humeral fracture due to a fall from a bicycle. Initial x-rays demonstrated fracture of right humeral greater tuberosity, slight displacement present, and good alignment. Initial evaluation recommended activity modification, sling immobilization, and medications. The patients provider has recommended right shoulder MRI and right shoulder arthroscopy, ORIF. However, the medical records do not support an indication for the requested MRI and surgery. Current evidence-based medical literature does not support the use of MRI for the evaluation of traumatic shoulder pain when radiographs demonstrate humeral head or neck fracture, as in this patients case. Overall, conservative treatment is recommended over surgical management of patients with proximal humeral fractures. This patients records do not provide a compelling rationale or extenuating circumstances to support the medical necessity of this request as an exception to literature recommendations. Therefore, the requested MRI of the right shoulder and right shoulder arthroscopy, ORIF surgery are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Velcade in combination with Xpovio and low dose dexamethasone. Xpovio is U.S. Food and Drug Administration (FDA) approved for the treatment of relapsed or refractory multiple myeloma in combination with dexamethasone in patients who have received at least four prior therapies, and are refractory to at least two proteasome inhibitors, at least two immunomodulatory agents, and an anti-CD38 monoclonal antibody. This patients disease has reportedly progressed despite treatment with Ninlaro, Revlimid, and dexamethasone as well as daratumumab and pomalidomide. Bahlis and colleagues reported on a phase 2 trial of 45 patients with relapsed or refractory multiple myeloma receiving Xpovio with Velcade and low dose dexamethasone (SVd). The authors found that this regimen produced high response rates without unexpected side effects. In addition, Grosicki and colleagues reported significant median progression free survival with SVd over Velcade with dexamethasone. The triplet combination of SVd is thus appropriate for this heavily pretreated patient with symptomatic disease. Given this support, the requested Velcade in combination with Xpovio and low dose dexamethasone are medically necessary for this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 liver transplant. Based on the available documentation, this patients  clinical status, with worsening decompensated cirrhosis complicated by hepatorenal syndrome, meets the American Association for the Study of Liver Disease (AASLD) guidelines for evaluation for liver transplantation (Martin, et al.). However, these guidelines also state that alcohol abuse is a contraindication to liver transplant. The United Network for Organ Sharing (UNOS) established a six-month alcohol abstinence requirement, which allows for assessment for improvement of liver disease (Marroni, et al.). In this case, the patient has documented significant recent alcohol abuse established by the presence of alcoholic hepatitis. There is a lack of research to support that patients may succeed if granted an exception to the six-month alcohol abstinence guidelines in this clinical setting (Daswani, et al.; Leon, et al.; Kodali, et al.). As six months of alcohol abstinence has not been established in this patients case, a liver transplantation listing is not supported by current guidelines and medical literature. For these reasons, the requested liver transplant 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a DOC Band cranial remolding orthotic device. Laughlin and colleagues found that positional skull deformities may be present at birth or may develop during the first few months of life and are generally benign and reversible. The authors recommended positioning and observation for mild-to-moderate deformity, noting that cranial orthoses should be reserved for severe cases of deformity or for the infant whose deformity does not improve after six months of age. Tamber and colleagues found, There is a fairly substantive body of nonrandomized evidence that demonstrates more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy, especially if the deformity is severe, provided that helmet therapy is applied during the appropriate period of infancy. In a randomized controlled trial of helmet therapy in 84 infants with positional skull deformation, Van Wijk and colleagues concluded, Based on the equal effectiveness of helmet therapy and skull deformation following its natural course, high prevalence of side effects, and high costs associated with helmet therapy, we discourage the use of a helmet as a standard treatment for healthy infants with moderate to severe skull deformation. In this case, the documentation provided reflected that the patients positional plagiocephaly was moderate. Given that current medical literature does not support the use of a cranial helmet in moderate cases of positional plagiocephaly, the requested equipment is not medically indicated. Therefore, a DOC Band cranial remolding orthotic device is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for water assisted liposuction of the arms, thighs, abdomen and buttocks. Researchers describe lipedema as a disorder characterized by localized adiposity of the lower extremities extending from hips to ankles, often occurring in females with a family history of the condition, and typically unresponsive to weight loss. The authors note that in addition to aesthetic deformity, the disease may cause pain in the lower extremities, particularly with pressure, as well as easy bruising. Researchers conclude that lymph-sparing liposuction using tumescent local anesthesia is currently the only effective treatment for lipedema. In this case, the patient has a diagnosis of lipedema. Visit notes reported that the patient underwent lymph-sparing lipectomy procedures for treatment of the legs, arms, abdomen, and buttocks approximately two years prior, but that she reported that swelling and pain had returned. She rated her pain as an eight or nine out ten on an average day, and at ten out of ten on bad days. A physical examination reported tender fat and nodules in the upper gluteal area, upper arms, forearms, abdomen, hips, thighs, knees, and lower legs. Undated photographs of the patient showed significant fatty fullness in the thighs and lower legs with some cuffing is present at the ankles. Given the patients diagnosis of lipedema and recurrence of symptoms, tumescent liposuction is considered standard of care. Therefore, water assisted liposuction of the arms, thighs, abdomen and buttocks 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 water assisted liposuction of the arms, thighs, abdomen and buttocks is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in plastic surgery and is actively practicing. Physician reviewer 2 is board certified in plastic surgery with sub-specialty certification in surgery of the hand and is actively practicing. Physician reviewer 3 is board certified in plastic surgery 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 a hospital bed, total electric with head, foot, and height adjustments, including side rails and mattress (HCPCS code E0265). Naddaf and colleagues describe inclusion body myositis as characterized by progressive asymmetric weakness predominantly affecting the quadriceps and/or finger flexors, with loss of ambulation and dysphagia as major complications of the disease. Aggarwal and Oddis report that there is no standard course of treatment for management of inclusion body myositis and that therapies are symptomatic and supportive. In this case, the patient has quadriplegic weakness with recent decline and generalized proximal and distal weakness. His quadriplegic weakness has progressed to the point that he is incapable of safe transfers to and from his bed to his wheelchair without the bed being raised to an elevated position. As he is unable to sit up on his own without assistance, he is at increased risk for aspiration pneumonia and pressure ulcers. Given that supportive management of this patients condition includes adaptive equipment, physical therapy, and home modifications if and as needed with the goal of functional independence and safety, the requested equipment is medically indicated. Therefore, a hospital bed, total electric with head, foot, and height adjustments, including side rails and mattress (HCPCS code E0265) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for inpatient rehabilitation.Findings: Three out of three physician reviewers found that the requested treatment of inpatient rehabilitation is likely to be more beneficial than any available standard treatment for the patients medical condition, complex regional pain syndrome in both feet and both hands.A review by Weissman and Uziel considered current treatment options for Pediatric complex regional pain syndrome (CRPS) and concluded that exercise and physical therapy are the main treatment cornerstones of all pediatric CRPS patients. A review by Hoffart and Wallace stated that the standard of care for pediatric amplified pain syndrome patients is multidisciplinary, which can be done through a multidisciplinary clinic or through appropriate referrals for counseling and therapies. They noted that evidence of the effectiveness of intensive interdisciplinary pain rehabilitation (IIPR) continues to accumulate.In this case, the patient has a diagnosis of an amplified pain syndrome, specifically CRPS of the hands and feet. The patient has tried and failed the standard of care, which includes a trial of medication management with multiple different classes of drugs. The patient has also tried injection therapy with little benefit as well as outpatient physical therapy and behavioral pain management. The patients current pain management provider has recommended that the patient warrants an intensive inpatient pain rehabilitation approach based on the severity of his disease and his failure to respond to standard treatments. Under these circumstances, the requested treatment of inpatient rehabilitation is likely to be more beneficial than any available standard treatment for the patients medical condition, complex regional pain syndrome in both feet and both hands.Final Result: The reviewer determined that the requested services are likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in neurology and is actively practicing. Physician reviewers 2 and 3 are board certified in anesthesiology, with subspecialty certification in pain medicine, 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.