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 brand name LoSeasonique tablets. LoSeasonique 20 ug with three-month dosing does not have a comparable contraceptive medication in the same class. In this case, the provider noted that the patient has been treated with medications similar to LoSeasonique with a lack of efficacy or intolerable side effects. However, the patients premenstrual syndrome, dysmenorrhea, depression, and anxiety have all been reportedly improved with brand name LoSeasonique. The American College of Obstetricians and Gynecologists (ACOG) supports treatment with brand name oral contraceptive medications when there are concerns regarding packaging or compliance, or when the name brand product is considered a better choice for the individual patient. Brand name LoSeasonique is a better choice for this patient in lieu of generic formulations as lower estrogen products have fewer side effects, and she has responded well to this medication. All told, the requested brand name LoSeasonique is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested brand name 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 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 a Stretta antireflux procedure. Current medical literature does not demonstrate that the Stretta procedure is superior to laparoscopic Nissen fundoplication (LNF) in the management of gastroesophageal reflux disease (GERD). Medical literature notes that while both LNF and Stretta radiofrequency may effectively and safely control GERD symptoms in selected patients, LNF was superior in improving symptoms and in eliminating proton pump inhibitor (PPI) therapy dependence. Researchers found that while treatment with Stretta was more effective than PPI therapy, it was less effective than fundoplication. Therefore, the requested Stretta antireflux procedure is not 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 Stretta antireflux procedure 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 service 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, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: The patient has requested reimbursement and prospective authorization and coverage for (1) zaleplon 30 mg (90 tablets per 30-day supply) and (3) zolpidem tartrate 20 mg (60 tablets per 30-day supply). The American Academy of Sleep Medicine clinical practice guidelines for the pharmacologic treatment of chronic insomnia in adults suggest the use of zaleplon as a treatment for sleep onset insomnia, and zolpidem as a treatment for sleep onset and sleep maintenance insomnia. The guidelines also strongly recommend the use of multicomponent cognitive behavioral therapy for insomnia for the treatment of chronic insomnia disorder in adults. The U.S. Food and Drug Administration (FDA) notes a maximum dose of 20 mg for zaleplon and of 10 mg for zolpidem tartrate. In this case, given the medication at issue is recommended for short-term treatment for sleep onset insomnia and may result in severe side effects at the requested doses, it is not medically indicated. Therefore, (1) zaleplon 30 mg (90 tablets per 30-day supply) and (3) zolpidem tartrate 20 mg (60 tablets per 30-day supply) were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was not and 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 internal medicine with sub-specialty 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an abdominal aortic aneurysm stent surgery. The Society for Vascular Surgery guidelines on the care of patients with abdominal aortic aneurysms (AAA) recommends surveillance imaging at 12-month intervals for patients with an AAA of 4.0 to 4.9 cm in diameter. The authors recommend endovascular repair as the preferred method of treatment for ruptured aneurysms. In this case, the patient has a large AAA measuring 5.5 cm with relatively rapid growth from his previous evaluation, along with an iliac artery aneurysm. Given the large size of this patients AAA and comorbidities that would increase his risk for open repair, endovascular repair is medically indicated. Therefore, abdominal aortic aneurysm stent surgery is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 surgery and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lidocaine 5% 50 gm (60 day supply with one refill). In a randomized controlled clinical trial, researchers evaluated pain control during vulvar biopsy after treatment with either application of 5% lidocaine-prilocaine cream or injection of 1% lidocaine. The authors found that, Patients randomized to lidocaine-prilocaine had a significantly better experience than those receiving injected lidocaine. The authors concluded that topical analgesics such as lidocaine 5% ointment can safely and effectively improve perineal pain. Researchers evaluated the effects of lidocaine-prilocaine cream versus local infiltration of lidocaine during repair of perineal trauma after vaginal delivery. The authors found that, Topical lidocaine-prilocaine cream gives comparable results in reducing pain during perineal repair after vaginal delivery. In this case, the patient has chronic pelvic and perineal pain. Her provider recommended lidocaine 5% ointment. The current medical literature supports treatment with anesthetic ointments as safe and effective for use in the pelvic and perineal areas. Given these findings, the requested lidocaine 5% 50 gm (60 day supply with one refill) is medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 a bone growth stimulator. According to a cohort study, for treatment of delayed unions and non-unions, low-intensity pulsed ultrasound bone stimulators can provide marginal benefit in patients 60 years of age or older with fracture risk factors (Zura, et al.). The authors reported that patients who used low-intensity pulsed ultrasound experienced a 96% healing rate while the expected averages are approximately 93%. In this case, the patient sustained a left foot injury several months ago and she presents with persistent left foot pain. The records do not indicate whether the patient has failed a trial of standard conservative management to include an adequate trial of immobilization and weightbearing restrictions. The submitted imaging reports do not document a nonhealing fracture of the base of the fourth metatarsal. The imaging report of the left foot MRI and serial radiographic reports demonstrating failed bone union are not included in the submitted medical records to support the diagnosis of delayed union or nonunion. Accordingly, the requested bone growth stimulator 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 bone growth stimulator 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 device 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, 2, and 3 are board certified in orthopedic 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for a RT300 Functional Neuromuscular Electrical Stimulation device provided by Restorative Therapies, Inc. Murphy and colleagues describe acute flaccid myelitis (AFM) as a disabling, polio-like illness mainly affecting children, and that the disease appears to be caused by non-polio enterovirus infection. The authors note that following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs and that patients engaged in multimodal rehabilitation can achieve functional improvements for years even after recovery of motor strength plateaus. Melicosta and colleagues report in a retrospective chart review of 31 patients with AFM who underwent activity-based restorative therapy (ABRT), including functional electrical stimulation (FES), that children with flaccid paralysis due to AFM undergoing structured, comprehensive rehabilitation interventions, even when these are initiated long after paralysis onset, can make significant neurologic and functional gains. The authors further noted that recovery of function and prevention of comorbidities are the main therapeutic targets for interventions in this population. Sadowsky and colleagues prospectively followed 25 patients with chronic spinal cord injury (SCI) who received FES during cycling and reported that FES was associated with an 80% change in neurological function: motor, sensory, and combined motor-sensory scores compared to 40% in controls. In this case, the patient has residual right arm weakness due to acute flaccid myelitis. In this clinical setting, the requested device is medically indicated. Therefore, the RT300 Functional Neuromuscular Electrical Stimulation device provided by Restorative Therapies, Inc. was medically necessary for the 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene expression test. Findings:  The physician reviewer found that records document that this patient presented with a diagnosis of malignant melanoma. According to the National Comprehensive Cancer Network (NCCN) guidelines, a melanoma with Breslow depth of 0.5 mm is clinically stage 1A. Even if the melanoma is slightly thicker, the melanoma was likely smaller than 0.8 mm with no ulceration, which is consistent with stage 1A. The treatment for this stage includes wide local excision. Swetter and colleagues noted that routine molecular testing, including gene expression profiling with DecisionDx-Melanoma is discouraged until better use criteria are defined. Treatment of thin melanomas measuring between 0.5 mm to 0.8 mm Breslow depth without evidence of ulceration, are treated with wide local excision per NCCN guidelines. Therefore, the DecisionDx-Melanoma gene expression test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the DecisionDx-Melanoma gene expression test was not 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 not likely to be more beneficial for evaluation 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 dermatology 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: An enrollee has requested authorization and coverage for polycarbonate lenses (code V2784), progressive lenses (code V2781), and anti-glare lenses (code V2745). Findings:  The physician reviewer found that Presbyopia is the age-related loss of accommodation and near vision. In this patients case, the presbyopia is significant enough that it requires corrective lenses to have functional vision. Although the degree of myopia and astigmatism is minimal, it is not unreasonable to correct it. Polycarbonate lenses are standard lenses that offer additional protection from accidental trauma. In this case, the patient has a history of LASIK, which weakens the structure of the cornea. Therefore, polycarbonate lenses (code V2784) are medically necessary for the treatment of the patients medical condition. The use of progressive lenses is not considered a medical necessity and is considered more a patient preference. Likewise, there is no medical necessity for anti-glare coating. Although the patient reports glare and halos at night, this is more likely to be related to the history of LASIK (which affects the asphericity of the cornea) and also due to the fact that her current glasses have the wrong prescription. Thus, progressive lenses (code V2781) and anti-glare lenses (code V2745) are not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that some of the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in ophthalmology 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 reimbursement for air and associated ground ambulance transportation services the patient received from Angel MedFlight.There is a lack of support for the services at issue in this clinical setting. Air medical transport is medically necessary when specific criteria are met. These criteria include: the patients condition must be such any form of transportation other than ambulance would be medically contraindicated; the patients condition is such that time needed to transport by ground poses a threat to survival; the individual is transported to the nearest hospital with appropriate facilities for treatment; and there is a medical condition that is life-threatening. When transporting from one facility to another, the above criteria must be met, and the first hospital must not have the required services and facilities to treat the patient. In this case, the patient was not being transported to another facility. He had been discharged from the hospital and was transported by air and ground ambulance to his home. Therefore, none of the air or ground ambulance transport criteria are met. Under these circumstances, air and associated ground ambulance transportation services the patient received from Angel MedFlight were not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were 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 emergency 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the peripheral dual x-ray absorptiometry (DXA) provided by Sutter Tracy Community Hospital. Cosman and colleagues note that in postmenopausal patients aged 50 and older, DXA measurements may be used to establish or confirm a diagnosis of osteoporosis, predict future fracture risk, and to monitor patients. The authors recommend that the DXA be performed in the lumbar spine (L1-L4), total proximal femur, or femoral neck when evaluating for osteoporosis. In this case, the submitted records do not demonstrate any extenuating circumstances for using peripheral DXA and there is a lack of evidence in current medical literature that peripheral DXA  is superior to a lumbar, spine. and hip DXA. Therefore, the peripheral dual x-ray absorptiometry (DXA) provided by Sutter Tracy Community Hospital 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 peripheral dual x-ray absorptiometry (DXA) provided by Sutter Tracy Community Hospital was 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 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 rheumatology 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: The patient has requested authorization and coverage for Norco 10 mg four times per day. The Centers for Disease Control and Prevention (CDC) guidelines state that, Nonpharmacologic therapy and nonopioid 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. Similarly, the Federation of State Medical Boards (FSMB) guidelines noted that, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. In this case, the patient was treated with Norco for chronic pain. However, the provider noted that the patient was concurrently using cannabis for nausea related to her HIV status. The patient also has a previous history of inconsistent urinalysis positive for cocaine. The provider expressed concern over the concurrent use of opioid therapy and cannabis. The provider initiated a slow opioid taper. The provider has acted in a manner consistent with the CDC and FSMB guidelines regarding chronic opioid therapy in patients who demonstrate an unfavorable risks for ongoing chronic opioid therapy. For these reasons, the requested Norco 10 mg four times per day 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 management 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.