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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for a Dexcom G6 transmitter, Dexcom G6 receiver, and Omnipod 5 supplies. Blood glucose monitoring is essential to diabetes management, with options including  self-monitoring with a fingerstick and use of a glucometer or use of a G6 continuous glucose monitor (CGM) such as the Dexcom G6. The American Diabetes Association (ADA) states, Real-time continuous glucose monitoring or intermittently scanned continuous glucose monitoring should be offered for diabetes management in adults with diabetes on multiple daily injections or continuous subcutaneous insulin infusion who are capable of using devices safely. The ADA further notes that insulin pumps should be offered for diabetes management to patients with type 1 diabetes who are capable of using the device safely, either by themselves or with a caregiver, and that the choice of device should be made based on patient circumstances, desires, and needs. Berget and colleagues report that the Omnipod 5 technology is a closed-loop system, with an insulin pump which can be synced only with the Dexcom G6 CGM and is able to adjust insulin delivery based on the blood sugar readings from the CGM. Brown and colleagues report that this system is safe and allows patients to significantly lower hemoglobin (Hb) A1c values and lessen glycemic variability, measured by time in the target range. In this case, the patient has demonstrated the knowledge and motivation to manage diabetes. While the patient's most recent HbA1c value of 6.3% indicated that diabetes is controlled, this value does not indicate whether the patient is still having wide glycemic variability or not. With use of the Dexcom G6 CGM and the Omnipod Dash insulin pump, the provider noted continued concern over the patients hypoglycemia. In this case, a closed-loop Omnipod 5 insulin pump and Dexcom G6 CGM may further benefit this patient in terms of reducing glycemic variability. Given the proven benefits of management of type 1 diabetes with the use of hybrid closed-loop insulin pumps and CGMs, the requested equipment and supplies are medically indicated. Therefore, a Dexcom G6 transmitter, Dexcom G6 receiver, and Omnipod 5 supplies are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment and supplies are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for HopeSeq Solid Tumors Comprehensive next generation sequencing (NGS) panel. Findings:  The physician reviewer found that This patient presents with carcinoma of unknown primary. The pathologic description was suggestive but not completely diagnostic. Molecular profiling based on gene expression or comprehensive mutational analyses has proven to be highly accurate in determining the tissue of origin, which will enable decision-making regarding appropriate therapies (Conway, et al.). In some small phase II studies, patients with carcinoma of unknown primary treated with medications selected based on their tissue of origin demonstrated better responses than patients who were treated empirically (Hainsworth, et al.). Moreover, there is evidence in the medical literature that mutational profiles can help aid diagnosis and guide therapy (Palma, et al.). The NCCN guidelines state that, Consider NGS in patients based on clinicopathologic features and where it guides therapeutic decision-making. The HopeSeq solid tumor panel is a NGS test for multiple mutations in cancer-causing genes in diverse solid tumors. All told, requested HopeSeq Solid Tumors Comprehensive NGS panel is 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 requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for 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 medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certifications in hematology and internal 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a consultation with a gastroenterologist specialist.The most recent guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) recommend procedural evaluation of bleeding, which is not documented in this case, and Gastroenterology consultation is warranted to determine if this is appropriate (ASGE Standards of Practice Committee, et al.). Additionally, Mott and colleagues recommend evaluation for alternative causes of symptoms, including fissure and inflammatory bowel disease. Guidelines from the American Society of Colon and Rectal Surgeons (ASCRS) and the American College of Gastroenterology (ACG) recommend workup for other causes of symptoms and various procedural interventions for hemorrhoids which do not respond to conservative medical therapy. ASCRS and ACG guidelines also support evaluation for other causes of symptoms such as anal pain and rectal bleeding.In this case, the patient is suspected to have hemorrhoid disease as a cause for anal pain and bleeding, although this has been ongoing for months without improvement with topical therapy, and multiple evaluations by multiple providers have not elucidated a cause for the patients symptoms or an effective treatment. The patient may have other pathology, such as fissure or inflammatory bowel disease, and evaluation for these would be consistent with evidence-based guidelines. The patient has had longstanding symptoms and evaluation by multiple practitioners without a cause for symptoms. Under these circumstances, the requested consultation with a gastroenterologist specialist is 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 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 reimbursement for osteochondral allograft of left knee. Findings:  The physician reviewer found that The records provided for review document that this patient presented with a cartilage defect that measured 2 cm. The patient underwent osteochondral allograft of the left knee. Pareek and colleagues noted that patients who presented with defects measuring less than 3 cm did not experience a statistical difference between microfracture and allograft. The authors concluded that osteochondral autograft transfer may achieve higher activity levels and lower risk of failure when compared with microfracture for cartilage lesions greater than 3 cm in the knee. Everhart and colleagues recommend first-line treatment without grafting in patients with lesions smaller than 3 cm. In this case, the defect is 2 cm. In this clinical setting, initial microfracture is as effective clinically than allograft transplant for management of this patients cartilage defect. Given these findings, the requested osteochondral allograft of left knee was not medically necessary for treatment of this patient. 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 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 patient has requested authorization and coverage for surgical repair of facial lesions and removal of facial cysts. Findings:  The physician reviewer found that Gallagher and colleagues note that in the dermatological use of intralesional triamcinolone in the treatment of acne, that observed skin atrophy rates are extremely low, but they are long lasting when it occurred. Min and colleagues report that while surgical excision is the treatment of choice for epidermal cysts, the cyst wall may be ruptured during operation, especially when the cyst wall is relatively thin, and that the incomplete excision of the cyst sometimes occurs because of a rupture of the cyst and may cause recurrence. In this case, given that the patient has a wound from a ruptured cyst secondary to a steroid injection in the glabella region, the requested service is medically indicated. Therefore, surgical repair of facial lesions and removal of facial cysts is medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the lesion is an abnormal structure of the body that is the result of the disease of acne and treatment of the acne cyst. The requested surgery is to create a normal appearance to the extent possible and will provide more than a minimal improvement as the patient currently has an obvious deformity of the skin, with a crater in the glabella region. For these reasons, surgical repair of facial lesions and removal of facial cysts is reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic 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

Findings:  The physician reviewer found that The patient has requested reimbursement for inpatient services. The records reviewed indicate that although this patient did not develop complications due to the head injury such as low blood pressure or continued vomiting, the patient did have significant pain that required treatment in the hospital. In addition, the patient was found to have an intracranial hemorrhage, skull fracture, and cerebrospinal fluid (CSF) leak. These factors support that the patients presentation was consistent with a moderate traumatic brain injury. Per the American Academy of Neurology (AAN) guidelines, the patient required admission to the hospital to be monitored for complications that may have necessitated immediate intervention (Giza, et al.). Moreover, the inpatient treatment setting was appropriate to monitor the patients serum sodium and perform repeat computed tomography (CT) studies. All told, the inpatient services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for percutaneous tibial nerve stimulation (PTNS) treatment. The records provided for review document that this patient presents with a history of overactive bladder. The patients provider reported that the available treatment options include PTNS, Botox injections, and sacral nerve stimulator implant. The patient has undergone treatment with Vesicare, Mirabegron, and Toviaz. Per the American Urological Association (AUA), after medication therapeutic failure or intolerance, PTNS is considered the least invasive therapeutic treatment option for patients with overactive bladder (Lightner, et al.). In addition, the AUA considers Botox and sacral nerve stimulators as more invasive treatments that should be reserved for patients who have failed behavior modification and pharmacologic therapy. This patients condition has failed to improve despite treatment with multiple medications and behavior modification. For these reasons, the requested PTNS treatment 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for proton beam radiation therapy (high dose of 70 Gy in 28 fractions). 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, and  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 for intermediate risk prostate cancer, as recommended by National Comprehensive Cancer Network (NCCN) guidelines. 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 radiation therapy (high dose of 70 Gy in 28 fractions) is 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for arthroplasty of first carpometacarpal joint, right hand. This patient is being treated for osteoarthritis of right first carpometacarpal joint. The patients symptoms began over two years ago and are interfering with her ability to perform activities of daily living. However, there is a lack of detailed documentation regarding trial and failure of recent reasonable and comprehensive less invasive conservative care measures. The records document that previous treatment with injection therapy occurred in 2020 and 2021. Treatment with thumb spica brace and medications were not noted on the most recent examination. Moreover, the patients physical examination did not reveal significant deficits that support surgical interventions. There are limited large-scale, long-term references demonstrating the safety and efficacy of the requested right hand arthroplasty of first carpometacarpal joint in this clinical setting. Huang and colleagues performed a systematic review on the peer-reviewed medical literature evaluating thumb carpometacarpal joint total arthroplasty for osteoarthritis. The authors reported that, Overall, the published evidence does not show that total arthroplasty is better than trapeziectomy and its variants yet there is a higher complication rate. Kollig and colleagues discussed that aseptic loosening of the prosthesis is likely the major cause of the high failure rates reported for cemented and uncemented types of implants. The authors concluded that, joint replacement may be considered as a possible treatment option for advanced osteoarthritis of the thumb carpometacarpal joint, but it should not always be recommended because long-term results are inconsistent and similar functional outcomes have been reported for alternative surgical techniques, such as resection arthroplasty. All told, the requested arthroplasty of first carpometacarpal joint, right hand 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services including physical therapy and occupational therapy. Findings:  The physician reviewer found that management of periprosthetic femur fractures after total hip arthroplasty are clinically challenging. Generally, well-fixed stems are treated with open reduction with internal fixation, and loose stems require revision arthroplasty . Rehabilitative care in this clinical setting focuses on early mobilization, maximizing function, and optimizing transition to the community when indicated .The records document that this patient sustained a fall at home and sustained a spiral fracture around the femoral stem of a prior left total hip replacement. The patient underwent surgical repair, which necessitated prolonged non-weight bearing restrictions. As of 6/25/22, the provider noted that the patient was not making functional progress and not initiating activities with therapies. The patient is also noted to have a history of progressive cognitive decline and a premorbid status of living alone, making community reintegration unlikely. Based on the patients records and recommendations in the medical literature, the patient is a candidate for treatment at the custodial level of care. There is a lack of documentation of an indication for ongoing SNF level of care services with physical therapy and occupational therapy. All told, the continued SNF services including physical therapy and occupational therapy were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation 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.