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

The enrollees parent requested authorization and coverage for genetic test, Coagulation Factor V gene analysis for Leiden Variant. The enrollee has irregular menstrual cycles, which are becoming heavier and she can skip up to one month. She also has cramps but medication has not helped. She has a headache and dizziness occurring every two weeks. The pediatrician noted a family history of Factor V Leiden mutation and recommended blood work to check for Factor V Leiden mutation in this enrollee. If negative, a prescription for birth control would be provided to the enrollee. The detection of genetic defects provides information that is helpful to determine the risks and benefits of using estrogen-progestin contraceptives. However, the medical literature does not recommend screening women who are taking oral contraceptives or estrogen replacement for inherited thrombophilia, unless a first-degree relative has inherited thrombophilia and clinical thromboembolic disease. There is insufficient evidence in the record the enrollee fulfills these criteria. Final Result: Three of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in obstetrics and gynecology and are actively practicing.  All three 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

An enrollee has requested authorization and coverage for Xyrem oral solution. In this case, the provider stated that the patient has a diagnosis of type 1 narcolepsy, an indication for which Xyrem is U.S. Food and Drug Administration (FDA) approved. However, the records provided for review do not support the diagnosis of narcolepsy. The diagnostic standards for narcolepsy require performance of a thorough multiple sleep latency test (MSLT). The polysomnogram/MSLT was not conducted in accordance with standard protocols. Notably, the patient did not sleep for the minimum 360 minutes required for performance of the MSLT. Rather, the patient only slept for a few hours on the night before the sleep test. Insufficient sleep on the preceding polysomnogram can cause false positives on the MSLT. Sleep onset rapid eye movement (REM) periods are not in and of themselves readily unique/exclusive to narcolepsy, but can be seen in insufficient sleep. Further, there was an adjustment made to the patients continuous positive airway pressure (CPAP) device during the polysomnogram portion of the study, which may have altered the patients sleep on the night before the MSLT. Based on the medical records provided for review, the patient has a diagnosis of obstructive sleep apnea (OSA). There are currently three U.S. Food and Drug Administration (FDA) approved therapies for the management of daytime sleepiness in OSA, which have greater support in the medical literature than Xyrem for sleepiness due to OSA. Therefore, Xyrem oral solution 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 medication is not likely to be more beneficial for treatment of the patients 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 is board certified in internal medicine with sub-specialty certification in sleep medicine and is actively practicing. Physician reviewers 2 is board certified in otolaryngology with sub-specialty certification in sleep medicine and is actively practicing. Physician reviewers 3 is board certified in in neurology 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

An enrollee has requested authorization and coverage for lumbar/sacral facet joint radiofrequency neurolysis on the right side.Medical literature supports that the requested services are medically necessary. The American Society of Interventional Pain Physicians (ASIPP) has stated in evidence-based guidelines that the evidence for therapeutic facet joint interventions is good for conventional radiofrequency. In this case, the patient has low back pain due to lumbar degenerative disc disease and previously had successful right lumbar radiofrequency ablation treatment which provided greater than 70% relief that lasted for more than 6 months. The patient more recently had the left side of her lumbar spine treated with a radiofrequency ablation which provided greater than 70% pain relief. The patient has already completed physical therapy within the last 6 months and is continuing with a home exercise program. Based on the current national ASIPP guidelines, a patient may undergo a repeat lumbar radiofrequency ablation if they reported at least 50% relief for at least 6 months, which is the case for this patient. Furthermore, the patient has participated in appropriate conservative treatment measures and is active in a home exercise program. The request for a repeat procedure is reasonable and consistent with the current national guidelines regarding the indications for this procedure. Under these circumstances, the requested lumbar/sacral facet joint radiofrequency neurolysis on the right side is medically necessary to treat the patients medical condition.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 anesthesiology, with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested authorization and coverage for Rezum: transurethral convective water vapor thermal ablation for a recent diagnosis of prostate cancer. The enrollee wishes to pursue radiation therapy to treat this condition.  He has concurrent diagnoses of chronic prostatitis and benign prostatic hyperplasia. His symptoms include difficulty initiating a urine stream and a restricted urine stream. The enrollee denied incontinence, painful urination or blood in the urine. The enrollee has tried Ciprofloxacin in the past, which has worked. Bactrim recently failed. The enrollees urologist recommended treatment with Rezum. Rezum is a system that uses water vapor therapy to decrease the size of the prostate. A search of clinical trials showed an ongoing study designed to evaluate the safety and efficacy of the Rezum system and assess its effects on urinary symptoms secondary to benign prostatic hyperplasia. The Rezum system has not yet been proven to be as safe or as effective as conventional treatments. Literature notes there is a lack of long-term follow up regarding this procedure. Currently, there is only one randomized control trial; providing data for a period of up to 48 months as part of a five-year trial. Further evidence and longer-term data are required to demonstrate the benefits provided by Rezum can be sustained. Since there is lack of any peer-reviewed article in the medical literature that supports the use of this treatment for those with prostate cancer. This procedure is approved by a government body for treating benign enlargement of the prostate. Literature describes the procedure as demonstrating significant improvements in symptom score, flow rate, and prostate volume reduction. However, the authors note the need for real-world data in comparison with other minimally invasive office-based therapies. Rezum has not been utilized in a randomized control trial of individuals with larger prostate size, or those with significant outflow obstruction. Additionally, those with a history of urinary retention or urinary tract infections have been excluded from the studies.Final Result: Two of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in urology and are actively practicing.  All three 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

The enrollee is requesting authorization and coverage for the medication, Tecfidera for multiple sclerosis. The enrollee wants to change to an oral medication. The neurologist prescribed Tecfidera as the enrollee has already used Copaxone and Glatopa. The enrollee is unable to self-administer the injections because of the large number of painful nodules that have developed in his suitable injection sites. The physician has indicated the appropriate therapy is to discontinue Copaxone and start Tecfidera, an oral agent, to treat his multiple sclerosis. Gilenya is not an appropriate therapy for this enrollee because he also has diabetes mellitus and Gilenya carries a cardiac and infection risk. The enrollee has multiple sclerosis and is currently on an injectable medication, but can no longer tolerate the injections. The other injectable formulary medication, interferon, would have similar problems. As such, an oral agent is medically necessary. Dimethyl fumarate (Tecfidera) is a well-studied oral agent with a good safety profile that is used to treat multiple sclerosis. It is a good alternative for those who do not want or cannot tolerate injectable medications. Literature notes dimethyl fumarate is an oral disease-modifying therapy approved for the management of relapsing-remitting multiple sclerosis individuals. Results from phase three clinical trials and follow-up studies provide good evidence of its efficacy and safety profile. Reported outcomes showed a stabilization or boost in health-related quality of life for those treated with dimethyl fumarate compared to placebo, reflecting higher enrollee satisfaction with therapy. General neurology standards of care for the treatment of multiple sclerosis allow for the use of any disease-modifying therapy that the provider feels is appropriate for the patient. Tecfidera is indicated for the treatment of patients with relapsing forms of multiple sclerosis. Given the patient has been utilizing Copaxone, but is having difficulty with his injections, it would be considered standard of care to change the patient to an oral medication.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient was diagnosed with bilateral knee osteoarthritis. The patient has been treated with bilateral knee surgeries and multiple bilateral knee viscosupplementation injections. The patient reported significant improvement with prior knee viscosupplementation injections. A few months after, the patient reported left knee pain. Physical examination findings included tenderness over the medial left knee. The patient has requested authorization and coverage for Supartz (hyaluronic acid) injections in both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Supartz (hyaluronic acid) injections in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, viscosupplementation has been tried for several years, with favorable results. Furthermore, the patients options are limited. The patient has tried and failed conservative treatments with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Supartz (hyaluronic acid) injections in both knees 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 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: Upheld Decision of Health Plan

The enrollee requested authorization and coverage for Prolia injections for osteoporosis. The patients internal medicine specialist indicated the enrollee cannot take Fosamax because of gastrointestinal upset. The recommendation was for the enrollee to start Prolia. The enrollee has very poor intravenous access and significant anxiety regarding intravenous catheter insertion. Prolia is used for the treatment of postmenopausal women with osteoporosis who are at high risk for fracture; treatment of glucocorticoid-induced osteoporosis in women at high risk for fracture; and treatment to increase bone mass in women at high risk for fracture receiving adjuvant aromatase inhibitor therapy for breast cancer. Medical literature indicates Prolia is not considered initial therapy for most patients with osteoporosis. Initial therapy for patients includes lifestyle measures and oral bisphosphonates. The medical literature indicates Prolia is for postmenopausal women with osteoporosis who are at high risk for fracture, defined as a history of osteoporotic fracture, or who multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy. The medical literature indicates a patients having gastroesophageal reflux disease does not mean they cannot take bisphosphonates. However, when gastroesophageal reflux disease is active, bisphosphonates are more difficult to use. Osteoporosis medications given intravenously instead of orally can help with gastrointestinal side effects. There is insufficient evidence in the record the enrollee has tried and failed bisphosphonates. There is also insufficient evidence the enrollee has a contraindication to the use of bisphosphonates, such as esophageal disorder or inability to sit upright for 30-60 minutes or chronic kidney disease. Denosumab is considered more effective than bisphosphonates only in cases where the patient has renal insufficiency. Since this enrollee does not have renal insufficiency or documentation of intolerance to oral bisphosphonates, bisphosphonates are still considered the first-line treatment for this enrollees osteoporosis. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology and 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

The patient has requested reimbursement for residential treatment center (RTC) services. The American Society of Addiction Medicine (ASAM) criteria, this patient met the Level criteria for Clinically Managed High-Intensity Residential Services. The patient demonstrated symptoms of withdrawal, including anxiety. She had the mental capacity to participate in therapy during her admission, but demonstrated poor impulse control outside of a structured environment. The patient was motivated to change, yet minimized the effects of her substance use problem. The providers notes that the patient required support and structure to acquire coping skills. The patient was at high risk for relapse, as she relapsed directly after she initially left the program. The patients recovery and living environment was inadequate to address her recovery as she had limited local supports, was homeless and her friends are substance users. Given these findings, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 with expertise in addiction 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

The enrollee requested reimbursement for endoscopic sinuplasty with balloon dilation. The enrollees otolaryngologist has recommended balloon or open surgery as the enrollees condition has not improved with aggressive medical therapy; both systemic and topical. The enrollee still complains of right frontal headaches. The enrollees otolaryngologist indicates a regulatory body has cleared the balloon catheter procedure for use as a surgical tool for opening the sinus ostia. This enrollees symptoms have not been relieved with comprehensive medical therapy. Her computed tomography scan shows opacification and obstruction of the right side sinus recesses frontal/sphenoid. Balloon sinuplasty has been shown to have long-term effects comparable to traditional surgery, with less recovery time, and the procedure allows for maintenance of the natural drainage pathways. Literature indicates endoscopic sinus surgery for those with chronic rhinosinusitis who have failed medical therapy has been performed in the office setting, under local anesthesia, for 14 years. Literature notes balloon catheter dilation is associated with low risks of complications and revisions. The procedure is well tolerated and effectively treats both chronic rhinosinusitis and recurrent acute rhinosinusitis. This enrollee underwent surgical sinusotomies. However, her symptoms persisted and she still complained of congestion and frontal headache. The clinical decision for advocating the use of balloon sinuplasty appears to be based upon this diagnostic. This would constitute objective evidence and indications for a balloon sinuplasty. Peer-reviewed literature demonstrates balloon sinuplasty would be more beneficial than standard treatments for this enrollee. It is a less invasive procedure than a sinus operation.Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in otolaryngology and are actively practicing.  All three 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.