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

Nature of Statutory Criteria/Case Summary: The enrollee requested reimbursement for the computed tomography (CT) scan of the maxillofacial/sinus. There is sufficient support for the services at issue in this clinical setting. CT scanning is the standard method of evaluating the sinuses. Moreover, Che and colleagues stated, Analyzing the CT features of bone changes in unilateral chronic maxillary sinusitis can improve the accuracy of disease diagnosis. In this case, the patient has a history of shortness of breath and fatigue as well as nasal symptoms. A CT scan was obtained to evaluate the sinuses for possible infection and surgery. Therefore, the CT scan of the maxillofacial/sinus was medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the service at issue was 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz (tofacitinib) tablets.Findings: According to the most recent published Alopecia Areata Consensus of Experts (ACE) guidelines, Janus tyrosine kinase (JAK) inhibitors would be the ideal choice of systemic therapy in adults. Treatment of alopecia totalis/universalis includes systemic steroids, methotrexate, cyclosporine, JAK inhibition, and contact sensitization with diphenylcyclopropenone (DPCP) or squaric acid. Few treatment methods have been evaluated by randomized controlled trials to determine the most efficacious modalities to treat alopecia areata.  Therefore, it is challenging for clinicians to guide patients regarding the best therapeutic options. In a recent study, JAK inhibition has shown efficacy and safety. Therefore, Xeljanz (tofacitinib) tablets are medically necessary for the treatment of the patients medical condition.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 dermatology 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: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis.Pelvic MRIs are appropriate to assess for further pathology in the setting of insufficient prior imaging or if an alternative diagnosis is being investigated. In this case, the patient has had the gold standard imaging over the past few years to assess for any abnormalities in her pelvis. The patients imaging has shown adenomyosis and uterine fibroids. There is no clinical documentation stating that this imaging was insufficient. She has already been diagnosed with adenomyosis on prior imaging, so repeat MRI is not indicated for this diagnosis. Therefore, MRI of the pelvis is not medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined the requested service is not medically necessary for evaluation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraosseous nerve ablation with the Intracept procedure at L4 and L5. The Intracept procedure is intended to be used in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain. Criteria for treatment with Intracept include at least six months of symptoms that have not responded to at least six months of conservative care and is accompanied by either Type 1 or Type 2 Modic changes on an magnetic resonance imaging (MRI). Fischgrund and colleagues reported on a multicenter randomized control trial involving patients with refractory low back pain and Modic changes in the treated vertebral bodies. The authors found significantly greater improvement in patient reported outcomes with the Intracept procedure at three months compared to patients treated with placebo. In this case, the patient is being treated for chronic neck and low back pain. The treating provider has recommended the Intracept procedure. One randomized controlled trial demonstrated the potential for short-term benefit, but data are lacking to support long-term efficacy and safety beyond three months. Clinical conclusions on this procedures safety and efficacy require longer-term data prior to determine whether the procedure is equivalent or superior to standard available therapies. All told, the requested intraosseous nerve ablation with the Intracept procedure at L4 and L5 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 intraosseous nerve ablation with the Intracept procedure at L4 and L5 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 services are 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 ** 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 authorization and coverage for a back brace. Findings:  The physician reviewer found that Back braces have not been found to prevent lower back pain. The North American Spine Society stated that there was insufficient evidence to recommend the use of bracing in patients with low back pain. Steffens and colleagues investigated the effectiveness of interventions for the prevention of low back pain. The authors noted that current evidence suggests that back belts do not prevent low back pain. In this case, the use of a back brace is being requested to treat mid back and low back pain. There is no radiographic evidence of spondylolisthesis, instability or fracture. There is a lack of support for the requested equipment in this clinical setting. Therefore, the requested back brace is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for diclofenac sodium gel 3%. Van der Heijde and colleagues describe the central role of non-steroidal anti-inflammatory drugs (NSAIDs) as a first-line intervention for ankylosing spondylitis. However, the authors do not mention topical NSAIDs specifically as a treatment option. In a study reviewing the use of diclofenac gel for acute musculoskeletal conditions, Wade and colleagues concluded that both ibuprofen/levomenthol and diclofenac gels provided superior global pain relief compared with ibuprofen gel, with a shorter median time to significant pain relief. In this case, the patient has a diagnosis of ankylosing spondylitis. While the records note that she is unable to tolerate oral NSAID therapy due to a history of gastrectomy, there a lack of data in current medical literature evaluating the use of diclofenac gel for the treatment of ankylosing spondylitis and comparing its use to current standard therapeutic options. Therefore, diclofenac sodium gel 3% is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested diclofenac sodium gel 3% 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 medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a Posey Bed (fully enclosed canopy style or enclosed sleep system). Sherberne and colleagues report that there is scant information in literature that discusses the use of an enclosure bed in a pediatric setting. The authors noted that in a review of 208 pediatric enclosure bed encounters in an acute care setting over a two-year period, there were several cases of falls, skin breakdown, and injury while using an enclosure bed. The authors noted sitter usage as an option for severely agitated children. In this case, the patient has multiple medical, developmental, and behavioral issues, including epilepsy, intellectual disability, agitated behavior, and severe mixed obstructive/central sleep apnea treated with continuous positive airway pressure (CPAP) therapy. In this clinical setting, a fully enclosed bed presents risks of injury or strangulation from the oxygen tubing and monitor wiring. Given these safety concerns, the requested equipment is not medically indicated. Therefore, a Posey Bed (fully enclosed canopy style or enclosed sleep system) is not medically necessary to prevent disease, disability, and other health conditions or their progression.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tongue radiofrequency volumetric tissue reduction. Medical literature notes that while continuous positive airway pressure (CPAP) devices are generally considered to be first-line treatment of most patients with obstructive sleep apnea (OSA), there are several alternatives, including surgical treatments. The authors further note that treatments that open the upper airway, such as radiofrequency ablation of the tongue, are more effective in improving apnea-hypopnea index (AHI) and oxygen saturation as compared to isolated nasal airway surgery. Researchers reported statistically significant reductions in respiratory disturbance index, Epworth sleepiness scale, oxygen desaturation, and snoring after multilevel temperature-controlled radiofrequency tissue ablation. Researchers observe that various techniques of volumetric reduction of the tongue are supported by literature for their positive impact on AHI and relatively minimal operative morbidity and long-term consequences. In this clinical setting, given that the patient has OSA and has failed CPAP therapy, current medical literature supports the use of the requested procedure as an effective second-line treatment. Therefore, tongue radiofrequency volumetric tissue reduction is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested tongue radiofrequency volumetric tissue reduction is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in otolaryngology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in sleep 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Inspire upper airway stimulation system. The U.S. Food and Drug Administration (FDA) approves the use of the Inspire device for the treatment of obstructive sleep apnea (OSA). In this case, the patients symptoms and test results are consistent with a diagnosis of OSA. A drug-induced sleep endoscopy (DISE) showed no concentric collapse at velum. The patient has been unable to tolerate continuous positive airway pressure (CPAP) therapy. In this clinical setting, the records support the use of the Inspire device, given the patients intolerance to CPAP, anterior posterior collapse, no central apnea, and body mass index (BMI) and apnea hypopnea index (AHI) within FDA criteria. Therefore, the requested Inspire upper airway stimulation system is 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 Inspire upper airway stimulation system 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 device 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 1 and 3 are board certified in otolaryngology and are actively practicing. Physician reviewer 2 is board certified in otolaryngology with sub-specialty certification in sleep 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 authorization and coverage for Repatha 140 mg/mL SureClick.The patient has established coronary artery disease and is status post coronary angioplasty. He has a strong family history of coronary artery disease and should be managed with intensive risk factor modification per American College of Cardiology/American Heart Association (ACC/AHA) guidelines. He had attempted combination therapy with atorvastatin/ezetimibe at highest doses, but his LDL level did not reach goal. Although rosuvastatin did get him to goal, it was not tolerated due to severe side effects. A reattempt at atorvastatin/ezetimibe, which would be the only other option to get him to goal along with lifestyle modifications, was unsuccessful. He was appropriately prescribed Repatha, which lowered his LDL level to goal without side effects. The patient meets published ACC/AHA guidelines for Repatha use. Therefore, Repatha 140 mg/mL SureClick is medically necessary for the treatment of the patients medical condition.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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for implant removal and breast lift. Researchers noted that, Women with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction. The American Society of Plastic Surgeons (ASPS) supports reduction mammaplasty for patients based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life. This patient complains of full body pain with no clear etiology. She complains of arthralgias, back pain, myalgias, neck pain and stiffness, in addition to chronic bilateral lower back pain with right-sided sciatica. However, there is no documented history of back, shoulder, and neck pain related to breast weight. There is no report of shoulder grooving or submammary rash demonstrated in the photographs reviewed. There is a lack of report of chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. In the absence of at least two quality of life signs, the requested implant removal and breast lift are not supported by ASPS guidelines as medically necessary. The patient underwent cosmetic breast augmentation in 2015 with 500 mL smooth silicone gel prostheses. She now would like for her breasts to be smaller with a prepartum appearance, and she is willing to undergo implant removal in order to accomplish this goal. She has a complex pain history that is not supported by clinical history or physical examination to be related to her breast implants. The records support that the patient has breast enlargement and ptosis as a result of the previous cosmetic placement of 500 mL breast implants. The amount of breast tissue that is proposed to be resected for the breast lift is 115 grams on her larger breast, and less on her smaller breast. The removal of 115 grams does not support that breast weight is the cause of pain or functional symptoms. For these reasons, the requested implant removal and breast lift 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections.Botox has not been found to benefit patients with temporomandibular joint (TMJ) disorder based on comprehensive reviews of the literature. According to Keenan, there is no consensus on the therapeutic benefit of Botox on temporomandibular joint disorder. Thambar and colleagues state that despite showing benefits, consensus on the therapeutic benefit of Botox in the management of myofascial TMJ disorder is lacking. In this case, the patient has a history of TMJ disorder. There is insufficient evidence on the therapeutic benefit of Botox for TMJ disorder. Therefore, the Botox injections are not medically necessary for the treatment of the patients medical condition.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 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.