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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the (1) telephone evaluation (CPT 99442) provided by Sheldon Jordan, M.D., (2) office visit (CPT 99214) provided by Sheldon Jordan, M.D., (3) advanced magnetic resonance imaging (MRI) (CPT 76498) provided by Sheldon Jordan, M.D., and (4) all or any of the repetitive transcranial magnetic stimulation (rTMS) (CPT 90868) received from Sheldon Jordan, M.D. Current medical literature supports the use of rTMS in the treatment of patients with fibromyalgia. Yang and Chang note that the results of a systematic narrative review suggest that TMS is beneficial for treating neuropathic pain of various origins, including from fibromyalgia. Lefaucheur and colleagues report that evidence suggest probable efficacy in the use of rTMS in improving the quality of life and decreasing pain in patients with fibromyalgia. Tanwar and colleagues found in a randomized controlled trial with follow-up at six months, average pain ratings and associated symptoms showed significant improvement post rTMS and the beneficial effects of rTMS lasted up to 6 months in the follow-up phase. In this case, the patient has a diagnosis of fibromyalgia. The patient has not responded to medications or physical therapy. Given that consultation with the provider and pre-procedure imaging were needed before initiating rTMS therapy, and that evidence shows that rTMS may be effective in treating fibromyalgia that is refractory to other treatment, the requested services were medically indicated. Therefore, the (1) telephone evaluation (CPT 99442) provided by Sheldon Jordan, M.D., (2) office visit (CPT 99214) provided by Sheldon Jordan, M.D., (3) advanced MRI (CPT 76498) provided by Sheldon Jordan, M.D., and (4) the rTMS (CPT 90868) received from Sheldon Jordan, M.D., were medically necessary for the evaluation and treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Saxenda 18 mg pen injector.Obesity is associated with increased risk of multiple comorbidities. Few medications are currently available for the treatment of obesity, and their effectiveness and benefits often fade when the drugs are discontinued. Saxenda (liraglutide) may be prescribed for chronic weight management as an adjunct to a reduced-calorie diet and increased physical activity. Nuffer and Trujillo noted, Data demonstrated that liraglutide can successfully achieve weight-loss benchmarks of 5% or more and 10% or more loss from baseline. In this case, the patient has struggled to lose weight despite a strict diet and regular exercise. Saxenda may assist this patient with losing weight and may have a positive effect in terms of her comorbidities related to her obesity, such as obstructive sleep apnea. Thus, the requested Saxenda 18 mg pen injector is medically necessary for the treatment of the patients 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 subspecialty 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 authorization and coverage for Entyvio infusions every four weeks. Findings: In the randomized placebo-controlled GEMINI I and II trials, patients with ulcerative colitis or Crohns disease who failed to achieve remission by week six continued Entyvio every four weeks rather than every eight weeks with satisfactory results. Additional studies have demonstrated the safety and efficacy of Entyvio for both induction and maintenance of remission, with remission in over 40% of patients after one year. In this case, the patient has demonstrated signs and symptoms consistent with active disease given the report of two to three bowel movements per day with bleeding and urgency. The patients laboratory testing revealed anemia as well as a low Entyvio level. Continuation of Entyvio dosed at every eight weeks would place the patient at risk for complications of partially untreated ulcerative colitis. For these reasons, the requested Entyvio infusions every four weeks are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 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 magnetic resonance imaging (MRI) of the right shoulder. Findings: Per the American College of Radiology (ACR), MRI can aid in detecting extra-articular abnormalities including osseous and soft-tissue findings that may predispose to or be the result of shoulder impingement. A study concluded that rotator cuff pathology accounts for most presentations of shoulder pain to primary care clinics. The authors noted that history and physical examination are important for excluding other causes of shoulder pain, while imaging assists in confirming the diagnosis and defining the severity of the abnormality. The ACR criteria state that MRI is considered the gold standard in the evaluation of the shoulder for entities involving the glenoid labrum and rotator cuff given its excellent depiction of soft tissue structure and evaluating a shoulder that failed to show pathology on x-ray. In this case, the patient is being treated for pain in the right shoulder. The patients progress notes indicate that their right shoulder pain is likely attributed to an accident. However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. In addition, the records do not include an x-ray report that failed to show pathology. Given these considerations, the requested MRI of the right shoulder is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for diagnostic molecular pathology (genetic testing) services. Based on the available published peer-reviewed studies and current guidelines, genetic testing to direct individualized treatment was likely the best approach in this patients evaluation and treatment. She was diagnosed with low grade serous ovarian cancer. Her provider recommended germline and somatic tumor testing to better assess and treat the patient. Due to emerging therapeutics for less common ovarian cancers, including low grade serous ovarian cancer, there is value in identifying potential pathways for treatment options and for potential clinical trial recruitment. Given this patients diagnosis of ovarian cancer, the genetic testing performed was indicated to help detect mutations and guide treatment. There are limited data in these cancers given their infrequency and it is difficult to acquire prospective data. All told, the diagnostic molecular pathology (genetic testing) services were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Findings:  Three of the three physician reviewers found the diagnostic molecular pathology (genetic testing) services were likely to be more beneficial for evaluation 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 evaluation 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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 3 is board certified in genetics 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 Euflexxa injections in the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as a routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of lasting good benefit from prior viscosupplementation. Furthermore, the options are limited. The patient has tried and failed other conservative treatments and arthroscopic surgeries, with the alternative being a total knee arthroplasty. Given this support, the requested Euflexxa injections in the right knee 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 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: An enrollee has requested authorization and coverage for bilateral knee replacements.According to Gademan and colleagues, the indications for a total knee arthroplasty include pain, loss of function, radiological changes with evidence of severe osteoarthritis, and failed conservative therapy. Further, Keurentjes and colleagues indicate that the results of the total hip and knee arthroplasty are better if the preoperative osteoarthritis is of a severe degree. In this case, the patient has severe pain and is unable to walk, indicating severe loss of function. The records document MRI evidence of severe osteoarthritis of the medial compartments of both knees and moderate to severe thinning and fraying of the patellar cartilage. Therefore, the requested bilateral knee replacements are 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 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: An enrollee has requested authorization and coverage for administration of the authorized Remicade infusions at a hospital-based outpatient infusion facility.Belonephobia (fear of needles), trypanophobia (fear of injections), and aichmophobia (fear of sharp objects) can lead to phobias requiring specific management. In both pediatric and adult patients, these phobias can result in elevated levels of anxiety and fear leading to the avoidance of care, and to interference with clinicians ability to perform procedures. McMurtry and colleagues stated, Individuals with high levels of needle fear who also have chronic health conditions requiring injections are a particularly vulnerable group who require treatment of their fear to maximize adherence to their medical regimen and avoid negative health effects. Repeated exposure to traumatic experiences, including in pediatric patients, can establish nonadherence to medication, long-term avoidance of medical care and follow-up, and subsequent negative health effects; these can result in complications and long-term disability in high-risk diseases, such as Crohns disease. In this case, the patient has Crohns disease at a young age and severe needle phobia. Crohns disease requires chronic and uninterrupted therapy in order to prevent complications. The records indicate that the patient has been able to undergo infusions successfully due to needle phobia mitigation at a hospital outpatient facility, but has had difficulty at other facilities. The therapy he is stabilized on is likely to control disease and prevent severe disease complications. Thus, administration of the authorized Remicade infusions at a hospital-based outpatient infusion facility is medically necessary for the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tirosint capsules. Findings:  The physician reviewer found that Recent guidelines of major endocrine societies recommend levothyroxine monotherapy for first-line use in hypothyroidism. While the various tablet forms of levothyroxine have been proven to be safe and effective treatment options for hypothyroidism, a capsule form of levothyroxine, Tirosint, contains no additives, such as lactose, gluten or cellulose, and may therefore be a good option for patients who are unable to tolerate other forms of levothyroxine. In this case, the patient is allergic to most forms of levothyroxine. However, the brand name Tirosint is a levothyroxine treatment that contains no additives or irritants to the patient. Therefore, Tirosint capsules are 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for deep brain stimulation (DBS) surgical procedure. Naesstrom and colleagues note that the U.S. Food and Drug Administration (FDA) has approved the use of DBS for the treatment of obsessive compulsive disorder (OCD). The authors further note that DBS has shown promising results for the treatment of therapy-refractory OCD. In a long-term follow-up study of 24 patients with severe, treatment-resistant OCD, Luyten and colleagues reported that electrical stimulation in the bed nucleus of the stria terminalis was a promising therapeutic option. In this case, the patient has a history of severe, medically refractory OCD and has tried and failed maximum standard medical therapy. Therefore, a DBS surgical procedure 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 deep brain stimulation (DBS) surgical 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 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, 2, and 3 are board certified in neurological 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a sodium fluoride positron emission tomography and computed tomography (PET/CT) whole body bone scan. Ravi Kumar and colleagues report that molecular imaging with PET/CT targeting the prostate specific membrane antigen (PSMA) receptor has emerged as a new standard in primary staging of prostate cancer. In this case, the patient has stage 4 prostate cancer. Visit notes reported a low platelet count of 9,000, which the provider noted precluded any form of radioisotope therapy. In this clinical setting, reducing radiation therapy based on an accurate delineation of existing lesions is essential and PET/CT currently provides the most accuracy in defining boney lesion anatomy. Therefore, sodium fluoride PET/CT whole body bone scan  is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested sodium fluoride positron emission tomography and computed tomography (PET/CT) whole body bone scan  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, 2, and 3 are board certified in urology 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 proton beam therapy. Current guidelines do not endorse the routine use of proton therapy in the treatment of all patient with Hodgkins lymphoma (Allen, et al.; Dabaja, et al.). Treatment of Hodgkins lymphoma generally consists of photon techniques utilizing intensity modulated radiation therapy (IMRT) and image guidance using breath hold techniques to minimize dose to the heart and lungs. However, in this patients clinical scenario, the field of treatment encompasses the entire anterior chest wall including the heart and lungs. Comparative dosimetry was performed, and proton therapy was able to significantly spare the mean heart dose by 50%. This reduction is sufficient data to support treatment with proton therapy with substantially improved sparing of the heart compared to standard IMRT with photon techniques (Hoppe, et al.). Treatment with proton therapy for this patient is expected to decrease long-term cardiac toxicities compared to IMRT with photon techniques. Therefore, the requested proton beam therapy 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 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.