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 and prospective authorization and coverage for (1) oxycodone-acetaminophen 10-325 mg (30 tablets for a 15-day supply), and (2) oxycodone-acetaminophen 10-325 mg to be filled for a 30-day supply. The Washington Agency Medical Directors Group guidance on prescribing opioids postoperatively recommends prescribing the lowest effective dose strength in cases of severe pain for 14 days or less. The authors note that for exceptional cases warranting more than 14 days of opioid treatment, the surgeon should reevaluate the patient before refilling the prescription and taper the patient off opioids within six weeks after surgery. On determining when to initiate or continue opioids for chronic pain, researchers 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. In this case, the patient was prescribed oxycodone-acetaminophen for fifteen days for acute pain from facial laceration, contusions of the abdomen and chest wall, closed head injury, and pain in the neck, right hip, and right shoulder following a motor vehicle accident. While the provider performed a CURES review and noted no aberrant behavior, the patient reported self-prescribing behavior with alcohol in his application for independent medical review. Current medical guidelines note that initial prescriptions for opioids may be medically necessary for the treatment of acute pain; however, continuation of opioid therapy is not recommended without a reevaluation by the treating provider and in cases where the risks may outweigh the benefits. Therefore, (1) oxycodone-acetaminophen 10-325 mg (30 tablets for a 15-day supply) was medically necessary for the treatment of this patient, and (2) oxycodone-acetaminophen 10-325 mg to be filled for a 30-day supply is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and is partially 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 anesthesiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for nasal/sinus endoscopy  along with the approved submucous resection inferior turbinate, partial or complete, any method and septoplasty or submucous resection, with or without cartilage scouring, contouring or replacement with graft. Findings:  The physician reviewer found that while chronic rhinosinusitis is often successfully managed in the primary care setting using antibiotics, topical or oral steroids, and saline nasal irrigation, surgery is an option when medical management fails.  In this case, the patient has a history of allergies and sinus infections, but the records do not reflect chronic sinusitis, which is defined as twelve consecutive weeks of symptoms, or recurrent acute sinusitis, requiring four or more provider visits in a year. The records do not reflect the patient has been evaluated or treated for allergies or migraines, which may cause recurrent or chronic sinus headaches. While a CT scan reported abnormal findings, it showed normal mucosa of the maxillary sinuses and an open ostiomeatal complex. Septal deviation is present in the majority of the population and is not an indication for surgery. Given that the records do not reflect chronic or recurrent sinusitis, the requested service is not medically indicated. Therefore, nasal/sinus endoscopy along with the approved submucous resection inferior turbinate, partial or complete, any method  and septoplasty or submucous resection, with or without cartilage scouring, contouring or replacement with graft is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 otolaryngology  head and neck 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endocardial implantation of a Watchman device. Findings:  The physician reviewer found that The records document that this patient had paroxysmal atrial fibrillation noted on an exercise test but not on the prior Holter examination. The patients CHADS-VASc score of 3 favors anticoagulation. He has no contraindications to anticoagulation therapy and no reported prior significant bleeding events. He has tolerated anticoagulation with Eliquis without complications. Currently, the Watchman device is recommended by the American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) guidelines for use in patients who cannot tolerate or have a contraindication to anticoagulation therapy (January, et al). Anticoagulation therapy remains first-line therapy for paroxysmal atrial fibrillation in the setting of an elevated CHADS-VASc score in patients who can tolerate it without significant contraindications. This patient has no reported contraindications to anticoagulation therapy or complications. The medical literature and guidelines support continued medical therapy in this patients clinical setting over implantation of the Watchman device. Therefore, the requested endocardial implantation of a Watchman device 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 endocardial implantation of a Watchman device  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 services are 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 subspecialty certification in cardiovascular disease 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 the Humira Pen 40mg/0.8mL Psoriasis Starter Kit followed by maintenance dosing. Psoriasis is a chronic inflammatory disease involving multiple organ systems and affecting approximately 2% of the world's population. American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis note that three classifications have traditionally been used to determine psoriasis severity. The severity of psoriasis is generally defined by the total body surface area (BSA) involved, and BSAs of <3%, 3% to 10%, and >10% are considered as mild, moderate, and severe disease, respectively. According to a study, mild psoriasis is usually treated with topical therapies, such as corticosteroids or vitamin D analogues. For severe psoriasis, guidelines state that biologics are usually recommended. Another study performed a systematic literature search to assess therapeutic options for patients with psoriasis and concurrent inflammatory bowel disease (IBD). The study concluded that adalimumab demonstrated efficacy in psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease. In this case, the patient has been diagnosed with severe psoriasis, with about 15% body surface area (BSA) affected. Records reflect that the patient was started on a mild-moderate steroid, triamcinolone, clobetasol, calcipotriene, and ketoconazole. While biologics would usually be recommended for severe psoriasis, the patient has a history of both psoriasis and ulcerative colitis, and the provider has recommended Humira (adalimumab) given its demonstrated efficacy for both conditions. Under these circumstances, the requested medication Humira Pen 40mg/0.8mL Psoriasis Starter Kit followed by maintenance dosing is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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 complete breast ultrasound. This patient with dense breast tissue has been evaluated with breast tomosynthesis examinations on multiple occasions over the last year. Per Kaplan, automated complete breast ultrasound has become a viable option for providing widespread ultrasound screening to fulfill this newly developing demand for adjunctive breast cancer screening. One disadvantage with breast magnetic resonance imaging (MRI) is that the studies of the breast are highly sensitive but have a relatively low level of specificity. Overall, the utility of complete breast ultrasound in this patient with dense breast tissue has been demonstrated in the medical literature (Shin, et al.; Kim, et al.; Giger, et al.). For these reasons, the complete breast ultrasound was 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 complete breast ultrasound was 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 reviewers 1, 2, and 3 are board certified in diagnostic radiology 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 reimbursement for platelet-rich plasma injections (CPT Code 0232T). Findings:  The physician reviewer found that platelet-rich plasma is a promising treatment modality with substantial evidence of safety. Houck and colleagues reported that the results of their systematic review of overlapping meta-analyses suggest that corticosteroid injection improves functional outcomes and pain relief for lateral epicondylitis in the short-term, while autologous blood and platelet-rich plasma are the most effective treatment options in the intermediate-term. Arirachakaran and colleagues provided additional results indicating that platelet-rich plasma injections can be effective in the management of chronic lateral epicondylitis. This patient presented with persistent left lateral elbow pain. Clinical examination findings were consistent with left lateral epicondylitis. There was also imaging evidence of extensor tendinosis with partial extensor tendon tear and edema in the capitellum. The patient failed long-term reasonable and comprehensive conservative treatment, including bracing, Voltaren gel, therapeutic exercises, and cortisone injections. Current evidence based medical literature supports the use of platelet-rich plasma for recalcitrant lateral epicondylitis. Therefore, the platelet-rich plasma injections (CPT Code 0232T) were 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 platelet-rich plasma injections (CPT Code 0232T) were likely to be more beneficial for treatment 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 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrogen breath test (CPT code 91065). Based on the clinical information provided, this patient presents with symptoms of abdominal pain, nausea, and constipation. Physical examination and radiographic imaging confirmed constipation. Previously, the patient experienced improvement with Senna therapy, but this has become less effective. The patient does not have risk factors to predispose her for small intestinal bacterial overgrowth (SIBO) such as gastrointestinal surgery or underlying condition such as anatomic abnormality, small bowel dysmotility, abnormal communication between proximal and distal gastrointestinal tract, or other systemic condition. Given the patients symptoms, testing for hydrogen breath test is not likely to improve the patients health outcome when compared to use of standard medical therapies for constipation and irritable bowel syndrome as supported by well-designed randomized controlled trials. In summary, the requested hydrogen breath test (CPT code 91065) is 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 requested hydrogen breath test (CPT code 91065) is 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 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral lumbar facet joint injections at L3-4, L4-5 and L5-S1. Researchers evaluated the effectiveness of lumbar medial branch blocks and facet joint injections in patients with chronic low back pain. The authors found that the proportions of positive blocks were higher in the intraarticular (54%) and medial branch (55%) groups than in the placebo group. The authors concluded that their results suggest that facet blocks might provide prognostic value before radiofrequency ablation. Researchers noted that, the evidence for lumbar facet joint nerve blocks using local anesthetics with or without steroid for managing chronic low back pain of facet joint origin is fair to good for short- and long-term improvement. The authors endorsed the use of medial branch blocks for diagnostic purposes, to help establish whether a patient may benefit from future radiofrequency ablation. In this case, the patient has chronic low back pain with degenerative disc disease on MRI affecting L3 through S1. Per the records, physical examination was notable for positive facet joint loading and negative for straight leg testing. There is no evidence of motor weakness or sensory abnormalities. The provider charted that the patient has tried and failed six weeks of physical therapy over six months as well as medication management including non-steroidal anti-inflammatory drug (NSAID) and opioid therapy. She has tried lumbar facet injection at these levels before at these levels and reported more than seven months of pain relief. The current peer-reviewed medical literature supports the use of diagnostic facet joint injections to establish whether a patients pain is facet joint related and whether the patient is a possible candidate for radiofrequency ablation procedure in the future. Therefore, the requested bilateral lumbar facet joint injections at L3-4, L4-5 and L5-S1 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensity modulated radiation therapy (IMRT) to the right breast. Findings:  The physician reviewer found that IMRT may be indicated in the treatment of breast cancer when conventional techniques are not adequate to meet dose volume constraints for critical normal structures (Hahn, et al.; Jackson, et al.). On review of this patients medical records, there is indication that standard dose metrics cannot be met with standard dose planning techniques using three-dimensional (3D) conformal treatment planning methods. A plan comparison demonstrated that the right lung was 30% with IMRT and 55% with standard 3D planning. The high lung dose with the standard 3D planning is well above the standard lung metric and would be associated with a high risk of lung toxicities. The reason the standard lung metric cannot be met with this patient is due to her large breast volume that requires treatment. Considering the patients unusual chest wall anatomy and support for IMRT to significantly reduce the volume of lung receiving radiation therapy, the requested IMRT to the right breast 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sirturo (bedaquiline fumarate 100 mg tablet), dosed at 400 mg daily for 14 days, then 200 mg daily for three months total therapy. Findings:  The physician reviewer found that  the available medical records, the provider has followed an appropriate plan of treatment with use of progressively more aggressive therapeutics for management of this patients Mycobacterium abscessus (M. abscessus). The provider initially used standard oral medications and transitioned when near pan-resistance was noted. He then escalated to prolonged courses of intravenous (IV) amikacin, and tigecycline, in addition to IV imipenem. Despite these measures, the patient has failed to completely respond, and she required a return to surgery earlier in 2020 to resect out the affected area. The next logical step is to consider novel therapies that have demonstrated in-vitro activity against atypical mycobacterial species. Per the U.S. Food and Drug Administration (FDA) approval for Sirturo, it is used to treat multi-drug-resistant tuberculosis, and the nature of mycobacterial isolates has similar in-vitro susceptibility. Brown-Elliott and Wallace demonstrated that Sirturo may have potential use in the treatment of disease caused by M. abscessus complex. The medical literature supports the efficacy of Sirturo in resistant mycobacterial pathogens. Thus, the requested Sirturo (bedaquiline fumarate 100 mg tablet), dosed at 400 mg daily for 14 days, then 200 mg daily for three months total therapy, is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Sirturo (bedaquiline fumarate 100 mg tablet), dosed at 400 mg daily for 14 days, then 200 mg daily for three months total therapy, 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 medication 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 internal medicine with subspecialty certification in infectious disease 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.