Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested hypoglossal nerve stimulation surgery for treatment of the enrollees obstructive sleep apnea (OSA).  Findings: Two physician reviewers found that although the requested surgery is not considered standard, there is adequate data supporting its efficacy in well selected patients who have failed standard available therapies. This patient has OSA and has failed prior surgical management including uvulopalatopharyngoplasty, nasal reconstruction and other techniques in addition to therapy and failure with CPAP as well as mandibular advancement prostheses. The American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) considers upper airway stimulation via the hypoglossal nerve for the treatment of adult OSA to be an effective second-line treatment of moderate to severe OSA in patients who are intolerant or who are unable to achieve benefit with CPAP. The most recent long-term peer-reviewed publication of upper airway stimulation for OSA by Woodson and colleagues demonstrated that patients achieved a definitive benefit from the implantation and electrical stimulation of the hypoglossal nerve for treatment of OSA. Clinically, this patient has failed prior surgical attempts, has been intolerant of the use of positive pressure airway therapy and has reduced his weight to have a body mass index below 32. Thus, the requested hypoglossal nerve stimulation surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested surgery 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: All three physician reviewers are board certified in otolaryngology 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: An enrollee has requested Epclusa 400 mg  100 mg, for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that the current medical evidence supports the requested medication regimen in this clinical setting.  According to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated, except those with life expectancy less than 12 months due to non-liver-related conditions.  The recommendations apply regardless of fibrosis stage.  Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive, genotype 3 patients.  A delay in treatment may result in decreased survival.  All told, Epclusa 400 mg  100 mg, one tablet daily for 12 weeks is medically indicated for the treatment of 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested intensity modulated radiation for treatment of the enrollees prostate cancer.  Findings: Three physician reviewers found that the current guidelines do not support the routine use of IMRT in the treatment of bone metastases.  IMRT uses dose painting and reduced treatment planning margins to create steep dose gradients adjacent to critical normal structures.  This level of complex planning is not necessary in the treatment of standard spine metastases.  Standard therapy for patients with spine metastases is with three-dimensional conformal techniques. There is a lack of data suggesting that treatment of these patients with IMRT results in decreased toxicity or improved local control compared to standard therapy with photon techniques.  Furthermore, the records do not document a clinical reason which would preclude the use of a standard three-dimensional technique using photons.  Thus, IMRT was not likely to have been of greater benefit than other treatment options.Final Result: Three reviewers determined that the services at issue were 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: All three physician reviewers 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 parent of an enrollee has requested magnetic resonance imaging (MRI) of the thoracic spine and MRI of the lumbar spine for evaluation of the enrollees low back pain. Findings: The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  This patient was found to have at least 8 degrees scoliosis on x-ray.  The patients provider was concerned that this degree of scoliosis was greater than that of idiopathic etiology.  The provider recommended trial of physical therapy, as the patients neurological status was normal.  The provider also recommended MRI scans of the thoracic and lumbar spine, and these were performed prior to commencement of physical therapy.  Per the current guidelines, the completion of physical therapy is not required first when the patient is a child and the examinations are performed as a combination for scoliosis.  Therefore, MRI of the thoracic spine and MRI of the lumbar spine, both without contrast, were medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90 mg  400 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions.  The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  This patient should be considered treatment-naive because there was not a failure of interferon-based therapy due to nonresponse or relapse.  The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  All told, Harvoni 90 mg  400 mg for 12 weeks is medically indicated for the treatment of 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  Findings: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this case, the patients breast tissue was described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis was likely to be more effective than other methods of evaluating this patient.Final Result: Three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  Findings: Three physician reviewers found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breast tissue has been described as dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been more efficacious than other methods of evaluating this patient.Final Result: Three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Cialis tablets for treatment of the enrollees low libido and low testosterone.  Findings: The reviewer found that Phosphodiesterase inhibitors including Cialis are the first-line therapy for the treatment of erectile dysfunction. The standard administration is on an as needed basis. Cialis 5 mg once daily is an option for treatment of men with erectile dysfunction. However, current medical literature does not support improved efficacy with use of daily Cialis in patients who are responding adequately to as needed Cialis therapy. For this reason, use of daily Cialis is not medically necessary for this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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

An enrollee has requested authorization and coverage for Botox injections. Findings:  The physician reviewer found that the request for Botox injections is not medically necessary for treatment of the patients medical condition. The patient presents with headaches, however it is not clear as to whether she has migraine or tension-type headache. She reports improvement after receiving Botox injections, but there are no records provided demonstrating the paradigm used or the dosage amount. The records also do not indicate if she has had headaches 15 or more days a month for over three months which would support the diagnosis of chronic migraine. In addition, there is a lack of documentation showing that the patient has tried other preventive treatment therapies for migraine such as beta blockers, anticonvulsants or tricyclic antidepressants. All told, the request for Botox injections are not supported as medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a power scooter for treatment of the enrollee, who is a T5 paraplegic.  Findings:  The physician reviewer found that power mobility can benefit specific individuals. This patient reported that he would like a power scooter to improve community mobility and lessen the physical demands of manual wheelchair usage which may be impacting his overall wellbeing. This patient has a personal mobility deficit and has safely used a power scooter in the past which improved his level of independent function. A power scooter is medically necessary to achieve the primary goal of spinal cord injury rehabilitation, maximizing the patients independence. Thus, in this patients case, the requested power scooter is medically necessary for 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 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 reimbursement for radiofrequency neurolysis for treatment of the enrollees back pain. Findings:  The physician reviewers found that although the current data do not provide a consistent recommendation for thoracic radiofrequency ablation, this patient has been through a number of conservative measures including medical supplementation and long-term narcotic use. The records document chronic pain status post thoracic wedge compression fracture. The patient has been treated with a number of interventions including medical bone building regimen. Due to the physiological changes created to the posterior columns, she has developed pain to the facets of the upper thoracic spine. Given the persistence of this patients condition despite treatment with conservative measures, the radiofrequency neurolysis was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in anesthesiology 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: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees sedative-hypnotic use disorder. Findings:  The physician reviewer found that the residential treatment center services were medically necessary, but not thereafter. Alprazolam is a short-acting, highly lipophilic benzodiazepine, which means it has a rapid onset of action with a short duration of clinical effect. These basic pharmacokinetic and pharmacodynamic properties make alprazolam highly addictive and extremely difficult for patients to discontinue once it is started. Based on the concerning history of substance use, coupled with medical comorbidity and co-occurring psychiatric illness, this patient was at heightened risk for a complicated withdrawal syndrome which supports the detoxification component of the admission. However, although chemical dependency and psychiatric specialty services were indicated, and the patient more than likely benefited from the placement, the medical records do not demonstrate the medical necessity of the residential level of care. Upon admission, the patient was noted to be intelligent, diligent, spiritual and motivated for treatment. She did not have any medical issues that warranted 24-hour medical care. She did not have any acute psychiatric distress. She recognized that alprazolam had become a self-defeating intervention and wanted to develop healthy coping skills to address her anxiety. Further, there is a lack of evidence demonstrating a home environment unconducive to sobriety while she had a very supportive and involved family. Her mother, father, daughter and granddaughter all attended a family program, allowing the patient to consolidate the positive family visit, close-out services and solidify aftercare planning. Therefore, residential treatment center services have been established as medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mobi-C two-level artificial cervical disc replacement (codes 22856 and 22858) for treatment of the enrollees left upper extremity radiculopathy and weakness.  Findings:  The physician reviewers found that cervical disc replacement is U.S. Food and Drug Administration (FDA) approved at one or two levels with Mobi-C. The peer-reviewed literature supports one- or two-level cervical disc replacement for specific indications of cervical disc degeneration and myeloradiculoapthy. There is evidence supporting net health outcomes in the presence of well-designed and executed randomized controlled trials with adequate follow-up on two-level cervical disc arthroplasty. In this case, the patient has significant stenosis at C5-7 with correlating clinical signs and symptoms of symptomatic cervical radiculopathy and is an appropriate candidate for a two-level cervical disc replacement. Based on the support in the peer-reviewed literature, two-level artificial cervical disc replacement is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested procedure 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 number one, two, and three are board certified in orthopedic surgery and 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.