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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. The records provided for review document that this patient has a history of Gleason 3+3=6 prostate cancer. The patients treatment plan includes moderately hypofractionated (28 fraction) intensity modulated protons directed at the prostate and seminal vesicles with use of hydrogel. There is a lack of medical evidence demonstrating that treatment with proton therapy is associated with a clinical benefit compared to photon therapy in the treatment of patients with prostate cancer. In addition, proton therapy has not been validated in a comparative randomized study to conventional treatment with photons. A recent multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy (IMRT) with photons (Vapiwala, et al.). The authors reported no significant difference in gastrointestinal or genitourinary toxicities or disease control between the two modalities. A position statement from the American Society of Radiation Oncology (ASTRO) noted that, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. The ASTRO position statement indicated that the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. Similarly, the National Comprehensive Cancer Network (NCCN) guidelines do not recommend proton therapy in lieu of photons using IMRT technique. For these reasons, the requested proton beam radiation 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Wegovy.Findings: A study indicates that obesity is associated with increased risk of numerous chronic diseases, including type 2 diabetes, hypertension, and cardiovascular disease. Additionally, the authors state, Weight loss of 510% results in improvements in cardiometabolic risk factors. Wegovy (semaglutide) is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs.  According to another study, these medications increase glycemic control (with a low risk of hypoglycemia) and reduce body weight, blood pressure and cholesterol levels. Another review indicates multiple studies have demonstrated this medications ability to promote weight loss, facilitating weight loss, via reduced appetite and energy intake, and delayed gastric emptying, and likelihood of health risks associated with this medication has been noted to be quite low. In this case, the patient has been diagnosed with obesity and has a BMI of 38. Moreover, the patients condition is complicated by hypertension and GERD. Therefore, Wegovy is medically necessary for 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the magnetic resonance imaging (MRI) of the right ankle. Welck and colleagues report that there are numerous stress fractures about the foot and ankle, including metatarsal, tibia, calcaneus, navicular, fibula, talus, medial malleolus, sesamoid, cuneiform and cuboid. The authors further note that late identification can be associated with protracted pain and disability, may predispose to non-union, and therefore necessitate operative intervention. Stress fractures are typically not visualized radiographically, and often diagnosed by MRI. Callachand and colleagues note that a diagnosis of avascular necrosis (AVN) should be considered in patients with atraumatic foot and ankle pain, especially in the presence of risk factors such as alcohol excess and smoking. In this case, the patient reported a painfully swollen, erythematous ankle that was unable to bear weight. There was no a history of trauma.  X-rays were unremarkable except for moderate soft tissue swelling.  Given that the records noted a history of alcoholism, the patient was predisposed to AVN. While AVN of the talus is relatively common in occurrence, such a lesion may not be evident on x-rays or on an ultrasound. Other occult lesions of the foot and ankle requiring advanced imaging may include osteomyelitis, septic joint, soft tissue infection,  osteochondritis ossificans, tenosynovitis among others. In this case, an MRI of the patients ankle showed subcutaneous edema at the dorsal and lateral margin of the ankle, moderate effusion, and moderate edema in and enhancement within the sinus tarsi, involving the adjacent talus and calcaneus, consistent with sinus tarsi syndrome. Given that these findings would not be evident with X-rays or ultrasound, the service at issue was medically indicated. Therefore, MRI of the right ankle was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was 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 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: The enrollees parent has requested reimbursement for cognitive FX concussion treatment services. There is limited evidence in current medical literature regarding cognitive, sensory, and related therapies for the treatment of post-concussion syndrome. Current guidelines do not provide guidance on the use of these types of therapies for treatment of post-concussion syndrome due to a lack of supporting data. In a meta-analysis and review of randomized controlled studies of cognitive behavioral therapy in adults with post-concussion syndrome, Chen and colleagues found no benefit from cognitive behavioral therapy for the symptoms of the post-concussion syndrome, although noting that such therapy may provide help for symptoms of depression, anxiety, and social integration. McNally and colleagues reported low level evidence supporting the use of cognitive behavioral therapy in providing improvement for post-concussion syndrome in children and adolescents. However, this was a non-randomized uncontrolled study, so it was not possible to determine if this effect was due to the therapy, placebo, or other bias. Therefore, cognitive FX concussion treatment services were not likely to have been more beneficial for treatment of the patients condition than any available standard therapyFindings:  Two of the three physician reviewers found the cognitive FX concussion treatment services at issue were not likely to have been 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 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 neurology with special qualification in child neurology 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 psychological testing.The American Psychiatric Association (APA) guidelines state, The initial psychiatric evaluation should include a review of the patients mood, anxiety level, thought content and process, perception, and cognition, and history of trauma and psychiatric history. According to medical literature, Most of the psychological tests do not fulfill high quality standards of psychometric testing. The authors conclude, The examined psychological tests for the assessment of cognitive abilities of psychiatric patients only partly conform to current standards of psychological testing. It is likely that the test results are of limited value. Misleading or even incorrect clinical evaluations might be a frequent outcome. In this case, there have been no cognitive issues identified by any providers that would indicate the need for neuropsychological testing. No psychology or psychiatry provider has questioned whether the patient has autism. According to the submitted documentation, the patient has failed to follow-up with treatment recommendations long-term. This would be the foundation of good psychiatric care, rather than a full battery of psychological testing for this patient. For these reasons, psychological testing is not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for nerve testing (autonomic testing) (CPT-95923) (CPT-95924) provided. Findings:  The physician reviewer found that Autonomic testing over the years has become the gold standard for diagnosis of POTS. Arnold and colleagues indicate, The most sensitive method to detect POTS is a detailed medical history, physical examination with orthostatic vital signs or brief tilt table test, and a resting 12-lead electrocardiogram. According to Goodman, The diagnostic evaluation of a patient with suspected POTS requires a thoughtful diagnostic approach. The authors state that this clinical examination involves an assessment of pupillary responses, an evaluation for sudomotor and vasomotor signs, and an assessment for joint hypermobility. Laboratory testing helps to exclude mimics of autonomic dysfunction, recognize conditions that may exacerbate symptoms, and to identify conditions that may cause or be associated with autonomic nervous system disease. The purpose of autonomic testing is to confirm a POTS diagnosis, exclude other causes of orthostatic intolerance, and may provide for characterization of POTS into neuropathic and hyperadrenergic subtypes. The medical evidence supports the services at issue in this clinical setting. Therefore, nerve testing (autonomic testing) provided was likely to have been more beneficial for evaluation of the patients medical condition. Findings: Three out of three physician reviewers found that nerve testing (autonomic testing) (CPT-95923) (CPT-95924) provided  was not likely to have been more beneficial for the enrollee than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturn.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in neurology. All reviewers 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 authorization and coverage for RT300 Functional electrical stimulator (FES) (HCPCS code E1399). The records document this patient has a history of right cerebrovascular accident (CVA) on in 2016 with hemiparesis. After a CVA, patients with resulting hemiparesis experience impaired use of upper extremities and impaired gait. Although some evidence suggests that FES cycling training can improve lower extremity motor functions and accelerate the recovery of overground locomotion in post-acute hemiparetic patients, there is a paucity of data that supports use of FES cycling for upper extremity motor recovery. Overall, there is a lack of high quality research demonstrating that FES cycling provides more benefit or better outcomes than standard therapy to improve posture or bone density or general fitness level in post-stroke rehabilitation. Therefore, the requested RT300 FES (HCPCS code E1399) is not 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 RT300 FES (HCPCS code E1399) 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 equipment 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 reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular 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 patient has requested authorization and coverage for (1) Gammagard intravenous infusions (two grams/kg monthly) and (2) administration of Gammagard in a hospital-based infusion center.  Findings:  The physician reviewer found that Neuromyotonia is characterized by muscle cramps and stiffness, often along with concurrent neuropathy, as in this case. Fleisher and colleagues report that treatment with phenytoin, carbamazepine, or gabapentin has provided symptomatic relief in some patients. The authors further note that for patients who do not respond to this type of treatment, immunotherapy with plasmapheresis, intravenous immune globulin (IVIG), or steroids may be beneficial. However, the authors conclusions were regarding a single case. Given that the evidence in current medical literature supporting the use of IVIG for management of neuromyotonia is limited and anecdotal, the requested service is not medically indicated. Therefore, (1) Gammagard intravenous infusions (two grams/kg monthly) and (2) administration of Gammagard in a hospital-based infusion center 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 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 Advair Diskus Aero Pow BR Act 100-50 mcg. Based on the available information, this patient presents with poorly controlled asthma. The provider charted that while on generic Advair, the patients symptoms worsened, which supports treatment with brand name Advair. The U.S. Food and Drug Administration (FDA) has approved Advair Diskus Aero Pow BR Act for the treatment of patients with asthma. Moreover, the Global Initiative for Asthma (GINA) supports treatment with Advair Diskus Aero Pow BR Act for the treatment of this patients asthma given her prior positive symptomatic response with this therapy and return of symptoms with generic Advair.  Therefore,  the requested Advair Diskus Aero Pow BR Act 100-50 mcg is medically  necessary  for treatment of 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 internal medicine with subspecialty certifications in pulmonary disease and critical care 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Monovisc injections (CPT-J7327) for both shoulders. Findings:  The physician reviewer found that Common nonoperative management of osteoarthritis include nonsteroidal anti-inflammatory drugs (NSAIDs), and intra-articular injection of corticosteroids. Intra-articular injection of hyaluronic acid has become accepted as an alternative treatment for the management of osteoarthritis.  A study by McKee and colleagues found, preliminary evidence that a single injection of non-animal hyaluronic acid may be efficacious over 6 months and well-tolerated in patients with symptomatic glenohumeral (shoulder) osteoarthritis. Moreover, Kany and colleagues indicate, Viscosupplementation allows implantation to be postponed until the shoulder becomes stiff and painful. In this case, the patient presented with bilateral shoulder pain. Additionally, the patient has a known history of osteoarthritis in both his shoulders. Due to his age, the patient desires to postpone bilateral shoulder replacement surgery. Therefore, the requested bilateral Monovisc injections (CPT-J7327) for both shoulders are medically necessary for treatment of 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 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 patients parent has requested reimbursement for durable medical equipment (DME) Wood-Cheneau-Rigo (WCR) custom thoracolumbar orthosis (TLSO) brace. Findings:  The physician reviewer found that the patient is a skeletally immature female who demonstrated a progression of scoliosis to a level that required intervention. The treatment of patients with adolescent idiopathic scoliosis is primarily limited to bracing and surgery. The use of bracing has been shown to slow or halt curve progression and may help avoid surgery. This patient was referred for a custom scoliosis brace that was fitted and reduced the patients curvature with use over several months. The current medical literature supports the use of custom bracing in the treatment of patients with adolescent idiopathic scoliosis to slow or prevent deformity progression and avoid surgical intervention (Weinstein, et al.; Minsk, et al.). Moreover, the specific type of brace provided in this patients case has been shown to be more effective than traditional custom bracing. Given these findings, the DME WCR custom TLSO brace was medically necessary for treatment of this patient. Final Result: The reviewer determined that the device 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 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.