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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI).Findings:  The physician reviewer found that  According to the American College of Radiology (ACR) appropriateness criteria for pathologic discharge in female patients under 30, There is no relevant literature to support the use of MRI in women <30 years of age with symptoms of pathologic nipple discharge. In fact, there is currently a lack of literature supporting the use of breast MRI for the evaluation of nipple discharge altogether, physiologic or pathologic, in patients under the age of 30. The ACR appropriateness criteria for the evaluation of nipple discharge note that for an adult female younger than 30 years old with pathologic discharge, evaluation by an ultrasound of the breast may be appropriate. In this case, based on the records provided, the discharge would be considered physiologic rather than pathologic. Notes reported two occurrences of a yellow-orange discharge on the patients bra. The records noted that the patients family history was negative for breast or ovarian cancer. The patient is not considered at an elevated risk for breast cancer. Therefore, bilateral breast MRI is not 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 bilateral breast MRI 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 and 3 are board certified in diagnostic radiology and are actively practicing. Physician reviewer 2 is board certified in interventional radiology and diagnostic radiology 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 stellate ganglion block and warm water therapy. In this case, the patient has a history of major depression disorder, anxiety, fibromyalgia, autism spectrum disorder, severe obesity and chronic pain syndrome. The patient is requesting a stellate ganglion block. However, there is a lack of support in the medical literature for treatment with stellate ganglion block in this patients clinical setting. A review by Lipov and colleagues evaluated the stellate ganglion block treatment for patients with post-traumatic stress disorder (PTSD). The authors concluded that, there have not yet been randomized controlled studies which demonstrate efficacy, although the authors and others have been advocating for these trials. Li and Loshak evaluated the stellate ganglion block for the treatment of patients with PTSD, depression, and anxiety. The authors found that, No relevant literature or evidence-based guidelines regarding the clinical effectiveness or use of stellate ganglion block for the treatment of depression or anxiety were identified. Furthermore, the authors noted that, The identified literature revealed mixed conclusions regarding the clinical effectiveness of stellate ganglion block for the treatment of PTSD. Thus, the requested stellate ganglion block is not medically necessary for treatment of this patient. Bidonde and colleagues compared the effectiveness of aqua therapy for the treatment of patients with fibromyalgia. The authors noted that, Low to moderate quality evidence relative to control suggests that aquatic training is beneficial for improving wellness, symptoms, and fitness in adults with fibromyalgia. The authors concluded that, Very low to low quality evidence suggests that there are benefits of aquatic and land-based exercise, except in muscle strength (very low quality evidence favoring land). Thus, regarding aquatic therapy there is also low quality evidence to support this treatment modality in lieu of conventional treatment modalities for management of this patients medical conditions. Accordingly, the requested warm water therapy is not medically necessary for treatment of this patient. Therefore, the requested stellate ganglion block and warm water therapy are 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for percutaneous implantation of a neurostimulator electrode with anesthesia. The records document that this patient has chronic low back pain with radiation into the legs. The patient has been treated with two back surgeries and multiple pain management procedures without adequate benefit. Medication management has been attempted with multiple drug classes including opioid therapy with diminishing benefit. Physical therapy yielded some benefit but without improvement in quality of life parameters. Additional treatment is being requested to include percutaneous implantation of a neurostimulator electrode with anesthesia. There is extensive evidence in the peer-reviewed medical literature demonstrating that spinal cord stimulation can be effective for the treatment of patients with failed back surgery syndrome. A review by Perez and colleagues found that spinal cord stimulation resulted in improved health related quality of life and functionality of patients with refractory pain due to failed back surgery syndrome compared to conventional medical management alone. Rojo and colleagues concluded that at two years, patients treated with spinal cord stimulation experienced greater improvements in their health related quality of life as compared to patients treated with conventional medical management. Given these findings, the requested percutaneous implantation of a neurostimulator electrode with anesthesia is medically necessary for 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 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 proton beam therapy. Proton beam has unique properties compared to standard photon or x-ray beam in its ability to deposit radiation doses. The use of proton beams potentially results in fewer areas of low scattered radiation dose as fewer proton beams may be used to achieve a dose distribution similar to standard photon beams. Proton therapy is currently utilized and strongly indicated in settings where severe toxicities would result if normal tissue constraints cannot be met by photon beam. However, in the setting of early stage prostate cancer there has not been a demonstrable clinically significant improvement in either quality of life or reduction of high grade toxicities. Sheets and colleagues report that among patients with nonmetastatic prostate cancer, intensity-modulated radiation therapy (IMRT) compared with proton therapy was associated with less gastrointestinal morbidity. Royce and Efstathiou report that the result of data on clinical evidence for proton efficacy and toxicity derived from both large claim-based datasets and prospective patient-reported data is mixed. There is a lack of evidence demonstrating a significant difference in overall survival or normal tissue toxicities over photon beam for early stage prostate cancer. While there are ongoing prospective trials investigating the potential benefits in disease outcomes and toxicities in this setting, no definite benefit has been demonstrated for proton beam in the setting of early stage prostate cancer. In this case, the patient has appropriately been recommended a course of definitive radiation treatment along with androgen deprivation therapy (ADT) for his intermediate risk prostate cancer, as recommended by National Comprehensive Cancer Network (NCCN). Given the lack of data supporting the utility of proton beam radiation for early prostate cancer, particularly for patients where the prostate and seminal vesicles rather than the comprehensive pelvic nodal chains are irradiated, the requested services are not medically indicated. Therefore, proton beam therapy is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical epidural steroid injection. Findings:  The physician reviewer found that  the patient presents with axial type neck pain without signs or symptoms of focal neurological deficits. The patients MRI demonstrated cervical stenosis at C5-6 and C6-7. The patient has tried and failed physical therapy and medication management. She recently underwent a cervical epidural steroid injection at C7-T1 with only 15-20% pain relief. The American Society of Interventional Pain Physicians (ASIPP) guidelines recommend repeat injections for patients who report at least 50% pain relief lasting at least eight weeks. The ASIPP noted that, In the therapeutic phase (after the diagnostic phase is completed), the suggested frequency of interventional techniques should be 2.5 to three months or longer between each injection, provided that greater than 50% relief is obtained for 2.5 to three months, not exceeding four per year, per region. This patients records do not include documentation to meet the criteria for repeat cervical epidural steroid injection. The records provided for review indicate the patient experienced 15-20% pain relief with a previous cervical epidural steroid injection, and follow-up was less than one month after the injection. Therefore, the requested cervical epidural steroid injection 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xyrem, Wakix, and/or Nuvigil. Findings:  The physician reviewer found that records provided for review document that this patient presents with a history of narcolepsy as demonstrated on polysomnogram followed by a multiple sleep latency test (MSLT). The patient has failed treatment with Vyvanse and Sunosi. The patients provider has recommended combination treatment with Xyrem, Wakix and Nuvigil. Per the American Academy of Sleep Medicine (AASM) guidelines, the requested combination therapy consisting of Xyrem, Wakix, and Nuvigil are appropriate to treat this patients narcolepsy . Xyrem, Wakix, and Nuvigil and each considered first-line medications for the treatment of patients with narcolepsy. Due to the severity of this patients daytime sleepiness, it is reasonable to use these agents in combination. Therefore, the requested Xyrem, Wakix, and Nuvigil are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications 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 subspecialty certifications in preventive medicine, pulmonary diseases, critical care medicine, and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ Nuspin 10 injector (quantity five, 30-day supply) and BD mini pen needles. Findings:  The physician reviewer found that Grimberg and colleagues report that idiopathic short stature (ISS), also called non-growth hormone-deficient short stature, is defined by a height standard deviation (SD) score at or below -2.25 SD and associated with growth rates unlikely to permit attainment of adult height in the normal range. The authors note that the height cutoff of -2.25 SD corresponds in adults to 63 inches for North American men. In this case, the patients growth chart and available clinical records do not demonstrate height Z-scores over -2.25 SD.  The records did not document normal brain magnetic resonance imaging (MRI), with and without gadolinium contrast, which is generally obtained before initiation of somatotropin. While direct height measurements of both biologic parents are preferred in cases of suspected growth disorders, the records included apparently self-reported parental heights, which may be significantly unreliable. The records documented that since the patient had entered puberty, his bone age had advanced slightly and yielded a predicted adult height of 63 inches, overlapping the lower limit of the normal range for North American men and consistent with his mid-parental target height (MPTH). Given that this patients growth pattern, pubertal timing, and bone ages have been consistent with his familial pattern of growth and development, and as patients recent growth velocity is within the normal range for early Tanner stage 2 in a male, the requested medication and supplies are not medically indicated. Therefore, Nutropin AQ Nuspin 10 injector (quantity five, 30-day supply) and BD mini pen needles are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication and supplies 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 prostatic artery embolization (PAE). As noted in the medical literature and American Urological Association (AUA) guidelines, the first-line therapy for the management of patients with BPH includes medical therapy with alpha blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors, and anticholinergic medication (Parsons, et al.). When patients fail to improve with medical management, some patients are candidates for treatment with transurethral resection of prostate (TURP). In patients with very large glands measuring more than 100 cc, as in this patient, holmium laser enucleation of prostate (HoLEP) and simple prostatectomy are recommended. There is a paucity of support in the guidelines or medical literature to support an indication for treatment with the requested PAE for this patients BPH. Moreover, there is a lack of trial data demonstrating improved efficacy of PAE over TURP, HoLEP, or simple prostatectomy. Furthermore, the European Association of Urology (EAU) guidelines reported that, A multidisciplinary team approach of urologists and radiologists is mandatory as the basis for future randomized controlled trials of good quality with long-term follow-up in order to integrate this treatment option into the spectrum of efficient minimally invasive treatment options. All told, the requested PAE 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 urology 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 An enrollee has requested authorization and coverage for bilateral GelSyn Injections (J7326).Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, there is a history of lasting excellent benefit from prior injections of GelSyn. Furthermore, other modalities such as physical therapy, home exercises, bracing, and cortisone injections have not been effective, with the only other alternative being total knee arthroplasties, which the patient wishes to avoid. Under these circumstances, the requested bilateral GelSyn Injections (J7326) are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denials should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested reimbursement and prospective authorization and coverage for (1) Monovisc injection to the right knee and (2) Euflexxa injections administered as one injection to the right knee and one injection to the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior viscosupplementation of the right knee. Given the patients limited options and based on the current medical literature, the services at issue were and are medically indicated. Therefore, (1) Monovisc injection to the right knee and (2) Euflexxa injections administered as one injection to the right knee and one injection to the right knee were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.