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 brachytherapy, image-guided radiation therapy (IGRT), and special radiation physics consultation for radiation therapy. The records document that this patient has a history of estrogen receptor (ER) positive, progesterone receptor (PR) negative, and human epidermal growth factor receptor 2 (HER2) negative right breast cancer. Following delivery of her child, this patients is planned to undergo radiation therapy with delivery of an initial photon-based external beam radiation treatment to the whole breast, followed by the boost treatment delivered with AccuBoost brachytherapy. The National Comprehensive Cancer Network (NCCN) guidelines recommend a course of adjuvant radiation treatment to the resected breast after a lumpectomy for patients with breast cancer in this patients clinical setting. The boost treatment is a dose focused on a small area of the breast that follows the initial treatment. The purpose of the boost is to administer a higher dose to the high-risk region of the breast, typically the lumpectomy site, without increasing the dose to the remainder of the breast. As recommended by the NCCN guidelines, there are several methods to deliver this boost including electrons, photons, and brachytherapy. For this patient, there are a few concerns regarding radiation dosing including complex and unusual anatomy as reported by the provider. Brachytherapy has the benefit of conformality since it may be inserted into or positioned around the lumpectomy cavity to reduce the amount of adjacent tissue exposure (Kauer-Dorner and Berger). Overexposure of the adjacent lung can lead to toxicities such as radiation pneumonitis or chronic pain from costochondritis. Moreover, given the patients young age, the risk of a secondary radiation-induced malignancy is correlated with the amount of tissue irradiated and results in a higher lifetime risk of secondary malignancy in comparison to more elderly patients (Xie, et al.). For these reasons, the requested brachytherapy with IGRT and special radiation physics consultation for radiation therapy are 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested reimbursement for ciprofloxacin 0.3% and dexamethasone 0.1% otic suspension (Ciprodex). Based on available clinical documentation, treatment with ciprofloxacin 0.3% and dexamethasone 0.1% otic suspension (Ciprodex) was medically necessary for treatment of this patients medical condition. The American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) clinical practice guideline on tympanostomy tubes in children states that tympanostomy tube otorrhea is usually a manifestation of acute otitis media and caused by Pseudomonas aeruginosa or common nasopharyngeal pathogens (Rosenfeld, et al.). In addition, the AAOHNS guideline stated that aminoglycoside-containing eardrops, often used to treat acute otitis externa, should be avoided in patients with tympanostomy tubes due to potential ototoxicity. The guidelines further recommend quinolone eardrops with or without steroids such as ciprofloxacin with dexamethasone to treat patients with middle ear infections. In this case, the patient had a tympanic membrane perforation, which is functionally similar to a having a tympanostomy tube since the membrane is not intact. In addition, the patients otorrhea culture demonstrated pseudomonas. In this clinical setting, the AAOHNS supports treatment with ciprofloxacin with dexamethasone otic suspension. Therefore, the ciprofloxacin 0.3% and dexamethasone 0.1% otic suspension (Ciprodex) was medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested reimbursement for hyperbaric oxygen therapy (HBOT) treatments. HBOT has been used for and is indicated for the treatment of compromised skin grafts and skin flaps. In this case, the records and a physical examination did not indicate there were any failed hypoxic skin grafts. Vyas and colleagues report that autologous fat grafts may be used for wound healing due to their abundance in progenitor cells. However, there is a lack of data and insufficient evidence in current medical literature supporting HBOT and fat grafting. Gandhi and colleagues report that multicenter studies must be conducted to determine HBOT's true efficacy, mechanism of action, risks, and advantages over conventional treatments. Therefore, HBOT treatments were not medically necessary for the 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Orthovisc injection series in the right knee at this time, and an Orthovisc injection series in the right knee in six months.Findings: Current medical literature pertaining to viscosupplemention reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried and the options are limited. In this case, there is a history of viscosupplementation with Orthovisc series every 6 months for 10 years with known benefit including pain relief, and functional improvement with regard to clicking and grinding. Accordingly, the requested Orthovisc injection series in the right knee is medically necessary for the patient's medical condition. Furthermore, the requested Orthovisc injection series in the right knee in six months is also medically necessary for the patient's medical condition.Final Result: The reviewer determined that the requested services are medically necessary for this patients medical condition. Therefore, the Health Plans denial should be overturned.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 continuous glucose monitor (CGM) device. The records provided for review document that this patient has a history of type 2 diabetes, hypertension, and anemia. The provider noted that the patient has vertigo, which interferes with her ability to check her blood glucose levels at regular intervals. Moreover, the patient is noted to have occasional erratic blood glucose levels. The U.S. Food and Drug Administration (FDA) approved CGM devices to record blood sugar levels at repeated intervals throughout the day and night in patients with diabetes (Olczuk and Priefer). CGM devices have been demonstrated to be clinically valuable due to the accuracy and convenience in the management of patients with type 2 diabetes. In addition, CGM devices can promote glycemic and weight control, help reduce the risk of hypoglycemia and hyperglycemia, and improve relevant lifestyle behaviors. CGM devices have become useful tools for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels (Zheng, et al.). Given this support, the requested CGM device 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 internal medicine with subspecialty certification in endocrinology, diabetes, and metabolism 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 L5-S1 lumbar fusion surgery. Bydon and colleagues noted a trial of conservative therapy should be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. The authors commented that these options may include physical therapy, epidural steroid injections, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion. Resnick and colleagues described that as a result of the decompression, the inherent instability associated with the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar fusion is considered appropriate to stabilize the spine and prevent delayed deterioration. The records document that this patient is being treated for vertebrogenic low back pain, lumbar radiculopathy, and inflammatory spondylopathy. The provider noted that the patient presents with back, left hip, and leg pain. Physical examination revealed a mildly antalgic gait on the left, negative straight leg raise test, and normal motor examination. The patients provider has recommended L5-S1 lumbar fusion. However, the records fail to include adequate documentation of recent, reasonable, and comprehensive less invasive conservative care measures for management of this patients back pain. The available documentation does not report that any recent treatment modalities have been attempted. In addition, dynamic flexion and extension films have not been provided to potentially assess the amount of movement at the L5-S1 level. Moreover, there is a paucity of large-scale, long-term published studies demonstrating the safety and efficacy of the requested L5-S1 lumbar fusion in this patients clinical setting. Given these findings, the requested L5-S1 lumbar fusion surgery 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 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 right anterior ethmoidectomy and maxillary antrostomy. Based on available clinical documentation, the requested right anterior ethmoidectomy and maxillary antrostomy are medically necessary for treatment of this patients nasal congestion with diagnosis of OSA. The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAOHNSF) clinical practice guideline on adult sinusitis state that objective confirmation of sinonasal inflammation can be acquired through anterior rhinoscopy, nasal endoscopy, and/or computed tomography (Rosenfeld, et al.). In this case, the patient has undergone evaluation with all three modalities. Anterior rhinoscopy and endoscopy revealed evidence of bilateral turbinate hypertrophy with severe right nasal obstruction. CT imaging demonstrated evidence of inflammation in the right ethmoid sinus and bilateral maxillary sinuses, as well as mucous retention cysts in both maxillary sinuses. The patient has undergone adequate attempts at conservative treatment with medical therapy with nasal steroids and antihistamines without adequate response. Given these findings, the requested right anterior ethmoidectomy and maxillary antrostomy are 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 otolaryngology 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 reimbursement for GeneSight genetic testing provided by Assurex. In this case, the patient presented to his provider with complaints of mental health decline over the previous few years due to a depressive episode. The patient indicated that his current medication for treatment of bipolar II disorder, panic disorder, generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD), was no longer effective. The patients provider recommended GeneSight genetic testing. In the peer-reviewed medical literature, Pardinas and colleagues noted that with regard to GeneSight genetic testing, there is a lack of large-scale replication studies, inconsistencies in defining valid treatment outcomes across experiments, a failure to routinely incorporate adverse drug reactions and serum metabolite monitoring in study designs, and inadequate investment in the longitudinal data collections required to demonstrate clinical utility. The current standard of care does not include genetic testing to assist in therapeutic decision making in the management of patients with mental health disorders including depression, GAD, PTSD, and bipolar disorder. Therefore, the GeneSight genetic testing provided by Assurex was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found that the GeneSight genetic testing provided by Assurex 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 psychiatry and is actively practicing. Physician reviewer 2 is board certified in psychiatry with subspecialty certifications in preventive medicine and brain injury medicine and is actively practicing. Physician reviewer 3 is board certified in psychiatry with subspecialty certification in preventive 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cardiac positron emission tomography (PET) scan. The records document that this patient has a history of a history of hyperlipidemia and diabetes. The patient underwent evaluation with cardiac PET scan. As noted in the medical literature, cardiac PET imaging can assess myocardial viability and blood flow to assess cardiac ischemia when SPECT imaging is inconclusive or contraindicated. However, prospective randomized clinical trials have not demonstrated the superiority of PET compared with SPECT imaging in the assessment of patients for possible coronary artery disease risk as in this patients clinical setting. The available documentation does not report that SPECT imaging was contraindicated or inconclusive. The current guidelines do not support the use of cardiac PET imaging in this role when other functional testing, such as SPECT, can be utilized. All told, the cardiac PET scan was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the cardiac PET scan 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 certification in cardiology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Euflexxa injection series (three injections to each knee). Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of severe tricompartmental osteoarthritis. The records document that this patient has excruciating knee pain and is not able to perform activities of daily living. The patient has been treated with and failed to substantially improve despite treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. Treatment with Synvisc-One caused an allergic reaction. The patient does not wish to have total knee arthroplasties at this time. The provider has recommended viscosupplementation with Euflexxa injection series of both knees. Consistent with the recommendations in the medical literature, the requested Euflexxa injection series (three injections to each knee) 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for staged excision of foreign body fat necrosis with antibiotic washout, debridement, and flap reconstruction of the hip area, legs, and gluteus maximus. The records document that this patient underwent buttock augmentation with injectable silicone or other substance at a non-medical facility after a previous gluteal augmentation with fat injection. The injected material is settling and causing deformity as well as tender and painful nodules. The patient presents with complaints of tender nodules and product migration to hip and groin folds with increased pain in buttocks, hips, and groin. The patient complains of numbness and tingling down legs, and intermittently feels unable to walk or feel the legs. A photograph received for review shows some skin darkening without evidence of induration or peau dorange. On review of the available documentation, it is not possible to remove the foreign material without excising a large amount of skin and muscle, with a result that will likely cause disfigurement and disability. Montrief and colleagues reported that, In the subset of patients presenting with silicone injection-based cosmetic buttock enhancement, special attention must be paid to local collections, as foreign material is present in affected tissue. In addition to hematomas and seromas, these patients may have a foreign body reaction with granuloma formation. Medical treatment as recommended by Kassamali and colleagues includes systemic steroids, hydroxychloroquine, and tetracyclines as first-line agents for silicone granulomas from injectable silicone, followed by tumor necrosis factor-alpha inhibitors for refractory disease. Based on the current medical literature, the requested staged excision of foreign body fat necrosis with antibiotic washout, debridement, and flap reconstruction of the patients hip area, legs, and gluteus maximus is contraindicated and 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.