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 sleep study at a sleep center. The records provided for review document that this patient is at high risk for comorbidities given his obstructive sleep apnea (OSA) and possible central sleep apnea based on his history. The patient has undergone evaluation with a home sleep study, which reportedly failed to capture sufficient time to fully assess the patients condition. The patients provider has recommended further evaluation with an attended in-lab sleep study due to failing the home sleep study. In addition, the patient is noted to be taking at least one narcotic medication. The treatment of a narcotic medication coupled with the high altitude at the patients home in Utah could lead to central sleep apnea. In this clinical setting, an in-lab attended sleep study is indicated to adequately evaluate and perform continuous positive airway pressure (CPAP) titration. Medical literature noted that the American Academy of Sleep Medicine recommends use of CPAP in the routine treatment of OSA in adults. All told, the requested sleep study at a sleep center is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 internal medicine with subspecialty certification in sleep 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for continuous glucose monitor (CGM) FreeStyle Libre 2 kit (sensor and supplies). This patients records document a history of type 2 diabetes that requires maintenance with insulin. The patients glycemic control has reportedly improved with use of a FreeStyle Libre CGM. The patients provider has recommended continued use of the FreeStyle CGM. As noted in the peer-reviewed medical literature, CGM is an emerging technique which can be useful for the management and are of patients with type 2 diabetes. The most common technique of CGM relies on a subcutaneous system, measuring an electric signal in the interstitial liquid, providing a measure of glycemia every five minutes (Breyton, et al.). Over time, CGM devices have been demonstrated to be clinically valuable due to its accuracy, convenience, and improvement of software. CGM devices can promote glycemic and weight control, reduce the risk of hypoglycemia and hyperglycemia, and improve relevant lifestyle behaviors (Zheng, et al.). CGM devices have been demonstrated to be a safe method, with high accuracy in glycemic values and a low complication rate (Bhasin, et al.). All told, the requested CGM FreeStyle Libre 2 kit (sensor and supplies) 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block. Occipital neuralgia is a debilitating pain condition that can be refractory to numerous available treatment modalities. Conservative treatment includes medications and occipital nerve blocks. When conservative options are inadequate, surgical intervention may be indicated. Researchers concluded that, Occipital nerve block as adjunctive therapy has shown safety and efficacy in treating patients with migraines, measured by the reduction in pain. Researchers reported that, Occipital nerve block with a local anaesthetic and corticosteroids provides a safe, simple, and effective treatment method for the patient with medically-refractory occipital neuralgia. In this case, the patient did not experience sustained relief with Medrol Dosepak or Tylenol. Thus, the occipital nerve block was the next appropriate treatment approach for management of this patients occipital neuralgia. Given this support, the occipital nerve block was 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 occipital nerve block was 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 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 reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography (CT) scan - (CPT 75571) CT heart, without contrast material, with quantitative evaluation of coronary calcium. Numerous clinical studies demonstrate that CAC scoring using ultrafast cardiac CT (also known as electron beam CT) adds predictive value in assessing risk of coronary heart disease (CHD). Budoff and colleagues note that a CAC score of zero was associated with a CHD risk of 1.3% to 5.6%, while a CAC score over 300 was associated with a risk of 13.1% to 25.6%. However, studies have not shown that CAC scoring adds value in the clinical management of asymptomatic patients in whom risk factors are targeted. In an examination of whether CAC scoring in asymptomatic adults had an effect on behavior modification, risk perception, and medication adherence, Mamudu and colleagues concluded that while CAC screening improved medication adherence, the impact of CAC screening on behavioral and lifestyle factors, perception of CHD risk, and psychosocial effects was not statistically significant compared with baseline. Aggressive medication management was the next step in treatment regardless of CAC scoring. Therefore, CT scan - (CPT 75571) CT heart, without contrast material, with quantitative evaluation of coronary calcium was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the CT scan - (CPT 75571) CT heart, without contrast material, with quantitative evaluation of coronary calcium was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 internal medicine with sub-specialty certification in cardiovascular disease 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for bilateral mastectomies. Catanzariti and colleagues noted that, ADH [atypical ductal hyperplasia] is one of the most common B3 lesions of the breast and the one with the highest risk of malignant transformation. It is therefore considered a non-obligate precursor of invasive cancer as well as an independent risk factor for breast cancer. The authors commented that, ADH is associated with a higher risk of invasive breast cancer, four to five times higher compared with the normal population. Racz and colleagues noted that, Histologically, ADH and low-grade DCIS [ductal carcinoma in situ] are virtually identical. Amersi and Calhoun reported that the final decision-making regarding prophylactic mastectomy depends on a womans long-term absolute risk, the current age and anticipated residual risk, the risks of prevention medication versus risks of surgery, the degree of risk reduction anticipated from each approach, and the patients preferences and values. While bilateral prophylactic mastectomy is not the treatment of choice for ADH, this patient has had both DCIS and ADH excised from breasts. The records document that the patient has undergone multiple interventions, and is concerned that another breast cancer will develop. The patient complains of severe disabling pain from most recent wide lumpectomy, as well as pain from the scar tissue from past lumpectomies in the other breast. Given these findings, the requested bilateral mastectomies 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for carotid artery surgery on both sides. Based on the documentation provided for review and current peer-reviewed medical literature, the requested carotid artery surgery is medically necessary for treatment of this patient. Researchers noted that, Medical management compared to carotid interventions in asymptomatic patients was associated with better early outcome during the first 30 days. However, the authors concluded that carotid revascularization was associated with improved health outcomes at five-year follow-up. This patients carotid duplex examination reported 50-70% stenosis, and an earlier study showed more severe disease including 90% on left side. In addition, the patients complaints of swelling and redness in the right groin surgical site also require thorough consideration and possible treatment. Overall, the documentation supports an indication for peripheral artery surgery and bilateral carotid endarterectomy. For these reasons, the requested carotid artery surgery on both sides 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. Credentials/Qualifications: The reviewer is board certified in general surgery with subspecialty certification in vascular 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: The patient has requested authorization and coverage for hydrocodone. A recent review from reported that, Anti-neuropathic analgesics may improve pain in IBS [inflammatory bowel syndrome], and deserve further, high-quality investigation, potentially considering parenteral administration and agents with minimal gastrointestinal motility effects. Researchers concluded that, Cognitive interventions such as cognitive behavioral therapy and hypnotherapy have demonstrated excellent results in IBS patients, but the limited availability and labor-intensive nature limit their routine use in daily practice. In patients who are refractory to first-line therapy, tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors are both effective to obtain symptomatic relief, but only TCAs have been shown to improve abdominal pain in meta-analyses. Furthermore, the Federation of State Medical Boards guidelines state that, opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the patient has chronic abdominal pain. The patients provider has recommended treatment with amitriptyline, Bentyl, and Imodium along with dietary changes and cognitive behavioral therapy (CBT) to assist with the patients anxiety and stress, which are noted to trigger her gastrointestinal symptoms. The guidelines do not report high quality data to support initiating chronic opioid therapy for this patients medical condition. Based on these findings, the requested hydrocodone 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for closed approach septoplasty. The records provided for review document that this patient has a history of nasal obstruction and septal deviation. The patient also has a contact point between the septum and the lateral wall, and she reports symptoms including facial pain. Septoplasty can improve the patients quality of life and improves facial pain in this clinical setting (Erdivanli, et al.; Altin, et al.). However, there is a lack of peer-reviewed medical literature reporting improved patient health outcomes with use of a closed approach in lieu of an open approach in this patients clinical setting. Moreover, the records suggest that using a closed approach would not facilitate completion of the entire surgical intervention as compared to an open approach. For these reasons, the requested closed approach septoplasty 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 otolaryngology with subspecialty certification in neurotology 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  right breast lumpectomy intraoperative radiation therapy (IORT) (CPT 77424 and 77469). Findings:  The physician reviewer found that recent National Comprehensive Cancer Network (NCCN) guidelines endorse the use of IORT in the treatment of well-selected patients with breast cancer. Moreover, phase 3 studies have shown equivalent outcomes in patients who undergo standard radiation therapy and IORT. The American Society for Radiation Oncology (ASTRO) recommends the use of IORT for breast cancer patients as well as counseling patients regarding the higher risk of ipsilateral breast tumor recurrence with IORT compared with whole breast irradiation, the need for prospective monitoring of long-term local control and toxicity with low-energy radiograph IORT given limited follow-up, and restriction of IORT to women with invasive cancer considered suitable (Correa, et al.).  Based on the ASTRO consensus statement, this patient falls into the suitable category and meets the criteria for the use of IORT. Therefore, the requested right breast lumpectomy IORT (CPT 77424 and 77469) 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 right breast lumpectomy IORT (CPT 77424 and 77469) 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 reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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 SpaceOAR Hydrogel procedure. As noted in the peer-reviewed medical literature, SpaceOAR Hydrogel spacer can be used during radiation treatment of the prostate to increase the space between the rectum and prostate and decrease the amount of radiation that is delivered to the rectum. In a randomized study of patients undergoing radiation for prostate cancer, researchers reported that, The use of a hydrogel spacer decreased dose to the penile bulb, which was associated with improved erectile function compared with the control group based on patient-reported sexual quality of life.  Moreover, the current National Comprehensive Cancer Network (NCCN) guidelines now endorse the use of a hydrogel spacer in patients undergoing radiotherapy for prostate cancer. For these reasons, the requested SpaceOAR Hydrogel procedure 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 Hydrogel procedure 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 reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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: The patient has requested authorization and coverage for (1) tramadol 50 mg tablets, (2) hydrocodone-acetaminophen 5-300 mg tablets, and (3) Nurtec ODT 75 mg tablets. Findings: The submitted documentation supports the medical necessity of a portion of the requested medications. On determining when to initiate or continue opioids for chronic pain, a study reported, Non-pharmacologic therapy and non-opioid 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 non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate.  In this case, given that the patient has not had relief with non-opioid medications for their chronic non-headache related pain, and the provider has recommended continued treatment with tramadol, (1) tramadol 50 mg tablets are medically indicated. Given that concurrent treatment with two opioids is not recommended, and as the patient may obtain relief from tramadol, the additional opioid, (2) hydrocodone-acetaminophen 5-300 mg tablets, is not medically indicated. Treatment for migraines may include medication options, such as triptans, and non-medication options, such as cognitive behavioral therapy. Nurtec ODT is a prophylactic and abortive medication used to help treat migraine episodes and is typically prescribed after failure of abortive medications, such as triptans, and prophylactic medications, such as beta-blockers. According to another study, calcitonin gene-related peptide antagonists, like Nurtec, should be reserved as second-line therapy for migraine headaches. Given that the records do not document that the patient has tried triptans and/or beta blockers, (3) Nurtec ODT 75 mg tablets are not medically necessary. Therefore, (1) tramadol 50 mg tablets are medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested medications is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is a licensed 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.