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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucynta 100 mg tablet (#120 per 30 days) and oxymorphone extended-release 10 mg tablet (#90 per 30 days). The Centers for Disease Control and Prevention (CDC) guidelines state that, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards guidelines recommend opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. The American Society of Interventional Pain Physicians advise providers to establish appropriate physical diagnosis and psychological diagnosis if available. In this case, the patient has tried and failed both pharmacological and non-pharmacologic interventions for management of her pelvic and vaginal pain due to pudendal neuralgia due to traumatic and vacuum assisted vaginal delivery. The patient has been stable and functioning well using a combination of Nucynta and oxymorphone as recommended by her provider. The records document that the patient has not shown any aberrant or drug seeking behavior and that the medications are managing the pain and allowing for the performance of  activities of daily living. In addition, there is no documentation showing that there has been any irregularities in the CURES report and there are no inconsistent urine drug screens documented. Based on these findings, the requested Nucynta 100 mg tablet (#120 per 30 days) and oxymorphone extended-release 10 mg tablet (#90 per 30 days) are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medications 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 anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for RT300 functional electrical stimulation (FES) therapy system. Findings:  The physician reviewer found that Reports from prospective randomized controlled clinical trials for the effectiveness of the RT300 FES cycling in patients with spinal cord injury (SCI) remains limited. There is insufficient evidence in the literature to support that the use of the RT300 FES will be effective for the treatment of patients with SCI. There is a paucity of data that the RT300 FES provides long-term improvement of muscle strength, vascular blood flow, bone mineral density, reduction of spasticity and atrophy, or facilitation of functional motor movement. Furthermore, with regard to circulatory function, a study by Barton and colleagues revealed that low-intensity FES increased blood flow during stimulation. However, there is a lack of evidence that these findings have a lasting effect on circulatory perfusion and reduce the risk of vascular complications. The  long-term health benefits of using  an RT300 FES  in the home is unclear as the evidence is insufficient to determine the effects of the technology on health outcomes. All told, the requested RT300 FES therapy system 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 the requested RT300 FES therapy system 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 reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Aortopathy genetic testing panel and sequencing and/or genetic testing service (CPT 81410). The records provided for review document that this patient has a history of hypermobility as well as a family history of aneurysms. The patient does not have a personal history of aneurysm. In addition, evaluation with echocardiogram was reportedly interpreted as normal. The provider noted that the patient has a history of cranial dissection, but additional information was not included for review. The provider noted concern for Ehlers-Danlos syndrome, and the patient underwent evaluation with genetic testing. Beridze and Frishman noted that vascular Ehlers-Danlos syndrome has a genetic basis. The combination of any two of the major diagnostic criteria should have a high specificity for vascular Ehlers-Danlos syndrome and further testing is recommended to confirm the diagnosis. Per the authors, the major criteria are arterial rupture, intestinal rupture, uterine rupture during pregnancy, and family history of vascular Ehlers-Danlos syndrome. Based on the documentation provided in this case, the patient does not meet the requirements for testing given the lack of major criteria. Harris and Lindsay stated that genetic testing can be beneficial for patients with a known diagnosis of thoracic arterial aneurysm. This patients records do not report a known personal history of thoracic arterial aneurysm. Overall, the patient did not have reported risk factors to support genetic testing for aortopathy or vascular Ehlers-Danlos syndrome. All told, the aortopathy genetic testing panel and sequencing  and genetic testing service (CPT 81410) were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the aortopathy genetic testing panel and sequencing and genetic testing service were not likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in rheumatology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in allergy and immunology and rheumatology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in rheumatology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Talicia 10-250-12.5 mg (four capsules every eight hours for 14 days). Chey and colleagues note multiple options for the first-line treatment of Helicobacter pylori including bismuth quadruple therapy, concomitant therapy consisting of a proton pump inhibitor (PPI), clarithromycin, amoxicillin, and metronidazole, or clarithromycin triple therapy. A rifabutin-based salvage regimen may be recommended after other treatment failures. In this case, given that the records do not show trial and failure of first-line regimens, the requested medication is not medically indicated. Therefore, Talicia 10-250-12.5 mg (four capsules every eight hours for 14 days) is not medically necessary for the 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nexlizet tablets. Findings: The U.S. Food and Drug Administration (FDA) approves the use of Nexlizet (generic name bempedoic acid/ezetimibe) tablets as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease who require additional lowering of low-density lipoprotein (LDL) cholesterol. However, there is a lack of randomized, blinded clinical studies establishing the long-term clinical outcomes and safety of Nexlizet in patient management. The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines on the management of blood cholesterol do not define the role of Nexlizet in this clinical setting. Therefore, Nexlizet tablets are not medically necessary for the 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 internal medicine with sub-specialty certification in cardiovascular disease 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

Findings:  The physician reviewer found that The patient has requested reimbursement for chiropractic services (CPT code 98940). According to the most current report, this patient reported an acute complaint in the left lower thoracic, lower thoracic, and right lower thoracic regions as well as difficulty performing personal care due to discomfort to the region. At that time, the patient rated the pain at 4/10. Significant objective findings included hypertonic right lower thoracic, lower thoracic, and left lower thoracic tissue tone, and limited entire thoracic spine range of motion. Based on the submitted documents, it appears that the patient had a flare of the condition and then underwent chiropractic manipulation. Evans and colleagues reported that spinal manipulation combined with exercise was more effective than exercise alone over a one-year period, with the largest differences occurring at six months. Goertz and colleagues concluded that chiropractic manipulative therapy (CMT) in conjunction with standard medical care can provide a significant advantage for decreasing pain and improving physical functioning when compared with only standard care. However, this patient reportedly received over 30 chiropractic sessions without documentation of functional improvement. Based on the lack of ongoing improvement with chiropractic care and frequent flare up of the patients symptoms chiropractic therapy was not indicated. All told, the chiropractic services (CPT code 98940) were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Ice compression sleeve (pneumatic compressor, non-segmental home model HCPCS code EO650RR). Findings:  The physician reviewer found that patient was being treated for unilateral primary osteoarthritis of the left knee. She underwent robotically assisted left total knee arthroplasty. She utilized an ice compression sleeve. However, there are limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and safe treatment for the noted pathology. Kwiecien and McHugh noted that cryotherapy can be utilized as a physical intervention in the treatment of injury and exercise recovery. Traditionally, ice is used in the treatment of musculoskeletal injury while cold water immersion or whole-body cryotherapy is used for recovery from exercise. Kunkle and colleagues reported that there is a lack of consensus whether the use of continuous cryotherapy devices leads to superior outcomes when compared with treatment with ice packs. This patients records lack detailed documentation of significant increased risk of deep vein thrombosis (DVT) or documentation that compression stockings and/or pharmacologic treatments cannot be utilized. Therefore, the ice compression sleeve (pneumatic compressor, non-segmental home model HCPCS code EO650RR) was 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 the ice compression sleeve (pneumatic compressor, non-segmental home model HCPCS code EO650RR) was 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 device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for AlloMap testing. The records provided for review document that this patient is status post transplantation in 1995 for myocarditis. The patient has experienced numerous complications including transplant vasculopathy as well as an embolic infarct from a left atrial appendage (LAA) thrombus. The patient underwent evaluation with AlloMap testing. In the peer-reviewed medical literature, researcher concluded that AlloMap testing was not inferior to routine biopsy in a study including clinically stable patients with a left ventricle ejection fraction greater than 45% who were one to five years status post-transplant. Acute cellular rejection is most likely to occur in the first six months after transplant, with a significant decline in incidence over time. This patient is more than 25 years post-transplant. In this clinical setting, the AlloMap testing was not likely to have been more beneficial than standard evaluation and testing. Therefore, the AlloMap testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the AlloMap testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for food allergy testing. The records provided for review document that this patient has a history of food allergies. The provider reports that the patient has experienced anaphylaxis, rhinitis and reactive airway disease. The patient is undergoing treatment for food allergies and the provider has recommended specific testing to help direct treatment. Oral food challenges and oral food desensitization programs are offered by a multitude of providers. Although oral food desensitization has reportedly been achieved in the majority of patients in randomized controlled studies, few patients successfully develop tolerance or sustained unresponsiveness. The standard of care in this clinical setting includes measurement of IgE levels to specific foods for an individual patient. However, an extensive array of blood tests and oral desensitization to a multitude of foods in the absence of a history of anaphylaxis is not supported by the peer-reviewed medical literature or clinical guidelines. Furthermore, there is a lack of evidence in favor of oral dosing protocols for foods that are considered intolerances or IgE-mediated allergies. For these reasons, the requested food allergy testing is not likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology with subspecialty certification in pediatrics 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for SpaceOAR hydrogel insertion (CPT code 55874). Hydrogel spacer can be utilized during external beam radiation treatment of the prostate to increase the space between the rectum and prostate and decrease the amount of radiation that is delivered to the rectum. In a randomized phase III study of patients undergoing external beam radiation for prostate cancer, Hamstra and colleagues found that the risk of late adverse events declined from 5.7% to 0% in the control versus hydrogel space group, and that the spacer group also had a significant reduction in bowel quality of life decline. In this case, however, notes dated 8/10/21 reported that the patient elected to undergo prostate brachytherapy, the placement of radioactive seeds into the prostate, which is already associated with a very low risk of rectal toxicity. There is a lack of data in current medical literature supporting the use of hydro-gel spacer in patients who undergo brachytherapy. The National Comprehensive Cancer Network (NCCN) guidelines for the management of prostate cancer do not endorse the use of hydrogel spacer in patients undergoing brachytherapy. Therefore, SpaceOAR hydrogel insertion (CPT code 55874) was not likely to have been more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the SpaceOAR hydrogel insertion (CPT code 55874) at issue was not likely to have been 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 not likely to have been 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.