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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for special leg compressing devices (segmental pneumatic compression device, high pressure, rapid inflation/deflation cycle, bilateral legs) provided during endometriosis surgery. The use of a mechanical compression device for the prevention of venous thromboembolism (VTE) in low-risk surgical patients is standard therapy in this clinical setting. The specific type of mechanical device is individualized. The American Society of Hematology (ASH) notes that for patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis and for pneumatic compression prophylaxis over graduated compression stockings. In addition, medical literature notes that mechanical prophylaxis, preferably with intermittent pneumatic compression, is recommended for low-risk abdominal-pelvic surgical patients as compared to no prophylaxis. Therefore, special leg compressing devices (segmental pneumatic compression device, high pressure, rapid inflation/deflation cycle, bilateral legs) provided during endometriosis surgery were likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the special leg compressing devices (segmental pneumatic compression device, high pressure, rapid inflation/deflation cycle, bilateral legs) provided during endometriosis surgery at issue were 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 devices at issue were 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 overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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 and prospective authorization and coverage for high frequency chest compression device. Findings:  The physician reviewer found that available documentation supports that this patient presents with significant neurologic and neuromuscular sequelae due to intracranial hemorrhage in infancy. The patient has inadequate airway clearance and requires assistance to mobilize secretions and prevent aspiration with subsequent pneumonia. The provider indicated that the patient has responded well to treatment with high frequency chest wall oscillation, with more manageable secretions and improved comfort. In addition, the peer-reviewed medical literature supports use of high frequency chest wall oscillation in well selected patients with neuromuscular disorders. High frequency chest wall oscillation was developed to improve airway clearance for use when normal mucociliary transport systems fail, as in this patients clinical setting. Fitzgerald and colleagues evaluated high frequency chest wall compression therapy in children with neurological impairments. The authors found that regular high frequency chest wall compression therapy may reduce the number of hospitalizations in neurologically impaired children. Lechtzin and colleagues commented that treatment with high frequency chest wall oscillation in patients with neuromuscular disease resulted in fewer hospitalizations and cases of pneumonia. The authors concluded that, our findings lend support to the routine use of this intervention in the care of patients with neuromuscular diseases. For these reasons, the high frequency chest compression device was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the equipment at issue was and 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 pediatrics with subspecialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has a history of BPH (benign prostatic hyperplasia). The patients symptoms include urinary hesitancy and nocturia.  The patient has been treated with Flomax but found that it was bothersome to his premature ejaculation.  His premature ejaculation has been a lifelong problem. The patient has also been treated with Rapaflo but stopped using it due to the cost; the medication was noted to improve his symptoms.  The provider recommended Tadalafil tablet 5 mg. The Health Plan indicates that the requested medication is not medically necessary for the treatment of the patients medical condition. At issue in this case is whether Tadalafil tablet 5 mg is medically necessary for the treatment of this patient. According to the 2021 AUA Guidelines for BPH, clinicians should offer one of the following alpha blockers as a treatment option for patients with bothersome, moderate to severe LUTS/BPH: alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin.  Lerner and colleagues reported, for patients with LUTS/BPH irrespective of comorbid erectile dysfunction (ED), 5 mg daily tadalafil should be discussed as a treatment option. Wang and colleagues, in a metanalysis of nearly 4,000 patients, stated tadalafil 5 mg once daily is an effective treatment for LUTS and ED with a low occurrence of side effects. The authors also noted tadalafil was well tolerated, and few patients withdrew due to side effects.  In this case, the patient was previously treated with tamsulosin which worsened his premature ejaculation and Rapaflo which was noted to be cost prohibitive. Tadalafil for BPH is endorsed by AUA BPH Guidelines as an appropriate treatment for BPH, especially in patients who do not tolerate alpha blockers. Therefore, Tadalafil tablet 5 mg is medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the brand name medication, Estrace Vaginal Cream. Estrogen is the most effective treatment for patients with moderate-to-severe symptoms of vaginal atrophy. As noted in the medical literature, estrogen therapy is appropriate for patients with symptoms of vaginal atrophy in the setting of low estrogen levels, provided there are no contraindications to this therapy. Adequate estrogen therapy can lead to restoration of a patients normal vaginal acidic pH and microflora, thickening of the epithelium, increased vaginal secretions and decreased vaginal dryness. The formulations available for vaginal estrogen therapy include conjugated estrogens (cream) and estradiol (cream, tablet, and ring). In a study reported by Lethaby and colleagues, the authors conducted a systematic review of 19 randomized trials included over 4,000 patients treated with local estrogen treatment. The authors found that creams, tablets, and rings were all similarly effective in relieving symptoms of vaginal atrophy. In this case, the patient has been maintained on brand name Estrace vaginal cream for many years with good response. An attempt at using generic estradiol resulted in an immediate adverse reaction. Thus, continuation of the brand name medication Estrace vaginal cream is appropriate for this patient. Therefore, the brand name medication, Estrace Vaginal Cream, is 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 obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility 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 hydrodilatation injection. Findings:  The physician reviewer found that The clinical consensus regarding treatment of frozen shoulder, or adhesive capsulitis of the shoulder, has been to address etiological factors if identifiable, addressing pain to allow for range of motion, initiation of a gentle range of motion program, and progression of the program over time. Interventions such as steroid injections or other analgesic measures can be considered during the painful stages of initiating mobilization to expedite recovery . A patients range of motion program can be started in a formal setting by physical therapists and can be transitioned to an independent program. Importantly, frequent range of motion exercise in the home setting has been shown to play a larger role in effectuating positive outcomes than the frequency of joint mobilization in a formal therapy setting. Combining hydrodilatation with corticosteroid injection has been proposed as an intervention to facilitate improvement, but the marginal efficacy of this technique over a standard steroid joint injection remains to be established in high-quality trials. Saltychev and colleagues noted that, hydrodilatation has only a small, clinically insignificant effect when treating adhesive capsulitis. Moreover, some data suggest that hydrodilatation injections are associated with potential adverse events such as increased pain and joint rupture. Overall, the proposed hydrodilatation procedure is not expected to improve this patients clinical course or outcomes in any clinically significant manner. Accordingly, the requested hydrodilatation injection 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 services are 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 services are 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 reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation 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: An enrollee has requested reimbursement for a Gel-One injection in the right knee.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 as to 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 severe pain in the right knee that did not respond to cortisone injections, medications, rest, heat, and restriction of activities. Records reflect that the patient was recuperating from shoulder surgery and was unable to undergo a total knee arthroplasty. Under these circumstances, the provider recommended viscosupplementation to relieve pain and delay total knee arthroplasty. Therefore, the Gel-One injection in the right knee was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for occipital nerve blocks. Findings:  The physician reviewer found that At issue is whether the requested occipital nerve blocks are medically necessary for treatment of this patient. Barmherzig and colleagues evaluated the current evidence and recommendations for the diagnosis and management of occipital neuralgia. The authors concluded that, Anesthetic block of the greater and/or lesser occipital nerves are often used both diagnostically and therapeutically. However, evidence is limited as most studies are noncontrolled. Occipital nerve blocks with or without corticosteroids yield transient benefit in most, with 15-36% sustaining extended relief for several months. Chowdhury and colleagues evaluated 72 different studies examining the role of the greater occipital nerve block for patients with headache disorders. The authors found that, the greater occipital nerve-block can be an effective acute and short-term preventive treatment option for migraine patients. Its long-term preventive efficacy however needs to be assessed by further randomized controlled trials. In this case, the patient has been diagnosed with chronic migraines and occipital neuralgia, which has been refractory to medication management with multiple classes of agents. However, the studies supporting the use of the occipital blocks have been too small or poorly designed to draw conclusions about their effectiveness for treating occipital neuralgia. Overall, there is a lack of studies evaluating the safety and efficacy of occipital nerve blocks to support their use in the management of this patients chronic migraines and/or occipital neuralgia. Therefore, the requested occipital nerve blocks 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 Tranylcypromine. Findings: The records document that this patient presents with a history of major depressive disorder non-responsive to multiple therapies including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), transcranial magnetic stimulation (TMS), and ketamine. In this case, the patients depression responded to the maximum U.S. Food and Drug Administration (FDA) recommended dosage of tranylcypromine 30 mg twice daily. The patients provider recommended titrating the dose to 40 mg twice daily to achieve remission. Per the FDA approval, tranylcypromine is indicated for the treatment of major depressive disorder in adult patients who have not responded adequately to other antidepressants. Studies have reported that patients who have not responded to multiple medication classes are likely to benefit from treatment with tranylcypromine. One study noted that tranylcypromine is being increasingly considered as a viable treatment option for patients experiencing severe courses of depression, such as treatment resistant depression and atypical depression. Another study reported that eight of 27 patients remitted with initial dosing of tranylcypromine up to 60 mg per day and six of 18 patients showed signs of remission with dosing up to 120 mg per day. In addition, a recent study of 28 patients with treatment resistant depression found that 21% of patients treated entered remission with an average higher tranylcypromine dose of 105 mg per day. Given these findings, the requested tranylcypromine is appropriate for management of this patients depressive symptoms. Moreover, the requested tranylcypromine is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. All told, the requested tranylcypromine 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 psychiatry with subspecialty certification in preventive 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Norco. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, 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. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The authors further note, Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The Federation of State Medical Boards (FSMB) states, 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. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has chronic back pain related to a past nephrectomy procedure. The records noted that the patient was taking Norco and Ambien concurrently, and that the treating provider expressed concerns about the increased risk of respiratory depression due to this combination. In this case, the treatment provider determined that the risks outweighed the potential benefits and requested that the patient select to continue either Norco or Ambien to avoid the risks associated with combined use. However, the patient declined to discontinue one of the medications. The patient has been referred to pain management for a trial of alternative treatment modalities. Given that this patient is being treated in a manner consistent with current medical literature, the requested medication is not medically indicated. Therefore, Norco is not medically necessary for the 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.