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 individual weekly therapy appointments, or any frequency of weekly therapy appointments. Based on the available records provided for review, weekly individual psychotherapy is reasonable and meets medical necessity criteria for this patient per American Psychiatric Association (APA) guidelines. The provider documented that the patient is experiencing acute anxiety and an exacerbation of post-traumatic stress disorder (PTSD) symptoms that interfere with her ability to function. In addition, cognitive behavioral therapy (CBT) remains the gold standard for the treatment of acute anxiety disorders. CBT is a time limited treatment and consensus guidelines recommend up to 15 weekly sessions. Given this patients symptoms, weekly individual therapy appointments are appropriate for this patients PTSD and acute stress. A review of randomized placebo-controlled trials provides strongly support the efficacy of CBT as an acute intervention for adult anxiety disorders, especially PTSD. Given this support, the requested individual weekly therapy appointments 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Foundation One genetic testing. Findings:  The physician reviewer found that a study of 86 patients and compared  the progression-free survival (PFS) on a regimen selected by molecular profiling to the PFS for the most recent regimen on which the patient experienced progression. The authors found that the regimen selected by molecular profiling offered a 27% survival advantage. The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of breast cancer supports a role for mutational analysis. For example, a BRCA1 and BRCA2 mutational analysis would open up the possibility of treatment with olaparib or talazoparib, while a neurotrophic tyrosine receptor kinase (NTRK) gene fusion analysis may open up the possibility of treatment with larotrectinib and entrectinib. In this case, based on the very aggressive nature of the patients tumors, mutational analysis is medically indicated. Therefore, Foundation One genetic testing is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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 deep sedation services. The American Dental Association guidelines for the use of sedation and general anesthesia by dentists states that moderate sedation, deep sedation, or general anesthesia is appropriate for individuals with significant medical considerations, for example with American Society of Anesthesiologists (ASA) classifications of ASA III and IV. In this case, the patient requires surgical tooth extraction. The patient reported anxiety regarding dental procedures. While the records reflect that the patient has requested intravenous general anesthesia, there is no documentation of medical necessity for deep sedation, such as previous  attempts to complete the proposed dental procedures with mild or moderate sedation. The records do not document that the patient has an ASA III or IV classification, or evidence of a difficult airway score. Therefore, deep sedation services are not medically necessary for the 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 anesthesiology with sub-specialty 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued physical therapy. The American Academy of Orthopaedic Surgeons (AAOS) guidelines include a strong recommendation for patients with symptomatic osteoarthritis of the knee to participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education. This patient presents with chronic bilateral knee pain. Functional limitations are noted in weight bearing tolerance. Clinical examination findings revealed bilateral range of motion and strength deficits. She completed six sessions of physical therapy without significant improvement. The patient has been instructed in an independent home exercise program. Additional work-up has been recommended to include an orthopedic consultation and bilateral knee x-rays. Current evidence-based medical guidelines recommend self-management programs for the treatment of this patients osteoarthritis. For these reasons, the requested continued physical therapy 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 Stelara injections every four weeks. Findings:  The physician reviewer found that mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, Kopylov and colleagues observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patients symptoms, such as recurrent abscesses, are consistent with active Crohns disease despite Stelara 90 mg every eight weeks. She has failed multiple biologic and conventional alternatives. A Stelara level of at least 4.5 ug/mL is associated with effective disease control, however in this case, the patients Stelara level was 2.4 ug/mL. Continuation of dosing every eight weeks or a change to another medication may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, Stelara injections every four weeks are medically necessary 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for compounded medication estradiol 20%, estriol 80%, and testosterone 0.1% topical, one gram daily. Custom-compounded hormones are multi-hormone regimens with dose adjustments based upon serial hormone monitoring. The hormones most commonly compounded are estradiol, estrone, estriol, progesterone, testosterone, and DHEA. The North American Menopause Society or American College of Obstetricians and Gynecologists do not support the use of custom-compounded hormones. In addition, there is a lack of evidence to support the safety and efficacy of custom-compounded hormone therapy when compared with standard estrogen and progestin formulations. Moreover, randomized trials have not demonstrated the safety and efficacy of compounded bioidentical hormone therapy for treating menopausal symptoms. Therefore, the requested compounded medication estradiol 20%, estriol 80%, and testosterone 0.1% topical, one gram daily is not medically necessary for 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 obstetrics and gynecology 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 hydromorphone tabs 2 mg (70 tablets).  Findings:  The physician reviewer found that 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 (FSMB) guidelines state that, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. In this case, the patient was on chronic opioid therapy with his previous pain provider. During a consultation with his current provider on 8/21/20, the treatment recommendations included weaning off opioids and soma due to an unfavorable risk-to-benefit ratio. The provider recommended to focus the treatment plan on non-pharmacologic treatments including pain management injections and possible back surgery. On 9/4/20, the patient was seen and the treatment plan involved ordering an epidural steroid injection for the neck. The provider also concluded that chronic opioid therapy was not indicated but did offer an alternative in the form of suboxone which the patient declined. Based on the available documentation, the patients records do not support an indication for hydromorphone. Moreover, the providers assessment suggests that the benefits of continued opioid therapy do not outweigh the potential risks in this clinical setting. For these reasons, the requested hydromorphone tabs 2 mg (70 tablets) are not medically necessary for 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SpaceOAR surgical transperineal placement of biodegradable material (CPT 55874). Specific concerns during prostate radiation include rectal toxicity due to exposure of the adjacent rectum to radiation. One mechanism of dealing with this issue is to create a space between the prostate and rectum, so that the rectum is out of the radiation treatment field and receives less radiation. A phase 3 study has been performed which examined the SpaceOAR system (Karsh, et al.). The authors reported that the patients who underwent treatment with the perirectal spacers had reduced rectal radiation and toxicity, with decreased rates of decline in bowel quality of life. The National Comprehensive Cancer Network (NCCN) now endorses the use of perirectal spacers for use during radiation therapy for prostate cancer. The NCCN noted that perirectal spacers can be utilized to improve sparing of the adjacent rectum. Based on the results of the positive phase 3 study and the endorsement by the NCCN, the requested SpaceOAR surgical transperineal placement of biodegradable material (CPT 55874) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested SpaceOAR surgical transperineal placement of biodegradable material (CPT 55874) 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 services are 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for VenaSeal ablation (CPT 36482-LT). Findings:  The physician reviewer found that the records do not include documentation to support an indication for VenaSeal in lieu of radiofrequency ablation for the treatment of this patients venous insufficiency. In the medical literature, Morrison and colleagues reported that VenaSeal for the treatment of greater saphenous vein (GSV) incompetence has a GSV closure rate at 36 months similar to that of radiofrequency ablation. The authors noted that patient improvement in quality of life outcomes were also sustained and similar between the two treatment groups. Although the VenaSeal treatment has been reported to show short- and intermediate-term results which are non-inferior to radiofrequency or laser ablation, there is a lack of data demonstrating that VenaSeal provides improved long-term health outcomes or freedom from re-intervention. All told, the VenaSeal ablation (CPT 36482-LT) 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 VenaSeal ablation (CPT 36482-LT) 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 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: Physician reviewers 1, 2, and 3 are board certified in surgery with subspecialty certification in vascular surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a hysteroscopy myomectomy procedure under a tertiary level of care. Vilos and colleagues note that for symptomatic fibroids causing menstrual abnormalities such as heavy, irregular, and prolonged uterine bleeding, hysterectomy is a definitive solution. The authors further stated that hysteroscopic myomectomy should be considered first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids.  In this case, the patients fibroids have resulted in a significant bleeding pattern requiring iron infusion therapy, emergent evaluations for heavy bleeding episodes. She has not responded to hormonal medication therapy. Evidence-based practice supports surgical intervention as medically indicated and clinically appropriate to treat this patients condition. Therefore, a hysteroscopy myomectomy procedure under a tertiary level of care is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested treatment 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 obstetrics and gynecology 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 Lyrica. Researchers describe diabetic peripheral neuropathy as a common cause of neuropathy that is unrelenting in nature, which can significantly affect quality of life. Researchers note that pregabalin is a first-line treatment in major international guidelines on the management of painful diabetic neuropathy. In this case, the patient has been diagnosed with diabetic peripheral neuropathy. The provider has prescribed Lyrica, a first-line therapy for the treatment of painful diabetic neuropathy. Therefore, Lyrica 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly psychotherapy services. The American Psychiatric Association (APA) practice guidelines for the treatment of panic disorder recommend psychosocial treatment, with the strongest evidence available for CBT, for patients who prefer nonmedication treatment and can invest the time and effort to attend weekly sessions and complete between-session practices. The guidelines further state that CBT is a time-limited treatment, generally 10-15 weekly sessions, with durable benefits. In this case, the patient has disabling panic attacks and symptoms of depression and anxiety. Her provider recommends continued therapy; however, due to limited availability, is unable to see her weekly. Given the patients symptoms and the current medical guidelines, a time limited course of CBT is medically necessary. Therefore, weekly psychotherapy services are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.