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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested functional electrical stimulation (FES) for treatment his medical condition.   Findings:  Two physician reviewers found that there is a lack of proven significant health or functional benefit of exogenous neurostimulation therapy of paralyzed muscles using FES cycle ergometry. There have been a number of small papers (case reports and series) published over the years providing some preliminary data suggesting possible benefits, but larger studies designed to evaluate the actual clinical efficacy of passive exercise such as FES cycle ergometry in the setting of spinal cord injury are lacking. Purported benefits of passive cycling, such as improving cardiovascular function, and bone density have not been sufficiently investigated to allow conclusions related to clinically-relevant outcomes. To date, the limited data that are available provide mixed results regarding health measures. In, sum there are insufficient data regarding clinically-relevant outcomes related to the use of this device on bone health after spinal cord injury. All told, the services at issue have not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Final Result: Two reviewers determined that the services at issue were not and 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:  All three reviewers are board certified in physical medicine and rehabilitation and are actively practicing. All three 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 food sensitivity testing for evaluation of her medical condition. Findings:  Three physician reviewers found that food allergy testing is not the standard of care for the diagnosis and treatment of irritable bowel syndrome. There is a lack of data from controlled trials that demonstrates that diets eliminating potential antigens identified through allergy testing improves gastrointestinal symptoms. This is because food intolerances and related symptoms are due to other factors in the food material and not due to an immune reaction. For the reasons provided, food sensitivity testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Three reviewers determined that the testing at issue was 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: One reviewer is board certified in medicine with sub-specialty certification in gastroenterology and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One reviewer is board certified in internal medicine and allergy and immunology and is actively practicing. All three 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 parent of an enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that a diagnosis of autism requires accumulating evidence from multiple sources, such as parent and teacher reports, clinical rating scales, and direct observation. In this case however, there are three evaluations. The first two conclude with a diagnosis of autism. The third evaluation finds that the patient does not have autism. The key differences between the evaluations are the differences in eye contact, shared activity, and quest for praise. These are noted as present in the most recent evaluation, but absent in the prior ones. This discrepancy may be due to differences in the examiner, differences in the behaviors of the patient on a day to day basis, or perhaps improvement/change in the patient between the examinations. However, it seems prudent to put the most weight on the most recent examination for multiple reasons. The most recent evaluation describes traits not seen in autistic children, and which are unlikely to fluctuate from exam to exam. In addition, the most recent evaluation comprises a large interdisciplinary team. Thus, the records submitted for review do not support a diagnosis of autism. As such, the requested ABA services are not medically necessary for treatment of the patients medical condition.  Final Result: Two reviewers determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatric neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. All three 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:  An enrollee has requested Benicar for treatment of her medical condition.  Findings:  The physician reviewer found that based on the records provided, the patient has essential hypertension that is being managed with an angiotensin receptor blocker medication, Benicar. There is no documented trial of other antihypertensive medications in the same class and no documented intolerance to other antihypertensive medications in the same class.  There are several other angiotensin receptor blocker medications in the same medication class that would be considered reasonable and appropriate to manage the patient's hypertension. Since efficacy and side effect profiles of antihypertensive medications are usually similar in medications of the same class, the Health Plans alternative should be effective and tolerated by the patient. As such, the medical necessity of Benicar has not been established in this case.   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 cardiovascular disease 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 parent of an enrollee has requested the Early Start Denver Model applied behavioral analysis (ABA) therapy for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that the Early Start Denver Model is medically necessary for treatment of the patients medical condition. There is evidence in the peer-reviewed literature that supports the Early Start Denver Model as effective for autism. A study by researchers concluded that participants in the Early Start Denver Model group showed significantly higher gains in developmental rate and receptive language. The Early Start Denver Model group has relationship building services built into this model. In this case, the patients current ABA therapy is providing progress. However, the parent feels that the patients progress can improve with a different model. At this point, it is medically reasonable to try a new model to see how much more the patient could learn because the window of the most gains is during this patients age range. Given the above, the requested services are medically necessary for treatment of the patients medical condition.  Final Result: Two reviewers 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: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics and child neurology and is actively practicing.  One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. All three 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this case, considering the asymmetry and dense nature of her breasts, an initial breast tomosynthesis was indicated.  Following the original study, it was recommended the patient have additional views as well as a sonogram.  The sonogram did demonstrate several benign appearing nodules and cysts.  However, there is a lack of support for a requested second breast tomosynthesis.  While the first tomosynthesis was indicated due to the heterogeneously dense nature of her breasts and the asymmetry, the second breast tomosynthesis was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: Two 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:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three 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: An enrollee has requested the Fentanyl transdermal patch for treatment of her medical condition. Findings:  The physician reviewer found that chronic pain that is unable to be cured can be considered palliative in nature and treatment. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. In this patient, the submitted records do not indicate that all non-opioid treatment options have been utilized. Further, the submitted records do not show that this patient has participated in behavior therapy despite much research supporting its use. In addition, the submitted documentation does not indicate an optimization of all non-opioid medications. Moreover, the records reflect that tolerance has taken place since the start of the narcotics as well as dose escalation. Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. The addition of more pure mu agonists will, for a short while, take care of the symptoms of mu agonist saturation; however, down regulation will transpire and then the patient is only back to where they started in terms of their pain perception. Studies reveal that such patients are worse off since they now have a much higher opioid tolerance level. Further, it does not appear there is a plan in place to monitor this patient with the medications both historically and currently.  Moreover, the submitted medical records do not discuss other standard mitochondrial myopathy treatments. Finally, multiple minimal requirements for opioid prescribing have not been met for this patient and the need to use opioids as the primary treatment strategy for pain has not been established. For these reasons, the requested Fentanyl transdermal patch is not medically necessary for treatment of the patients medical condition.   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 sub-specialty 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 cryosurgical ablation of renal carcinoma for treatment of her medical condition. Findings:  Two physician reviewers found that the literature demonstrating the efficacy of cryoablation for small renal cell carcinomas is limited to single institution case series without direct comparison to surgical resection.   Per the medical evidence, laparoscopic partial nephrectomy is the standard of care. Although several meta-analyses have pooled the data on cryoablation and demonstrated equivalent disease control, the follow-up is relatively short and the total volume of cryoablation reported in the literature is small. Current recommendations would be to reserve cryoablation for poor-risk patients or those for whom parenchymal resection may impact their kidney function.  In this patients case, the records document no apparent comorbidities or underlying renal disease.  In sum, the requested cryosurgical ablation is not likely to be superior over other treatment options in this patients case.  Final Result: Two 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:  All three reviewers are board certified in surgery and are actively practicing. All three reviewers are 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 radiofrequency neurolysis for treatment of her medical condition. Findings:  Three physician reviewers found that the current medical evidence does not support the requested services in this clinical setting.  Interventional pain procedures may be utilized for the treatment of severe musculoskeletal pain when conservative treatments with medications, exercise and physical therapy have failed.  In this case, the records showed subjective report of pain relief with objective measures of functional restoration following the diagnostic facet procedures.  However, the subjective, objective and magnetic resonance imaging (MRI) findings is consistent with radicular low back pain.  The records did not show that the patient has failed conservative treatment with NSAIDs, exercise, physical therapy and behavioral modification.  In sum, the requested services are not likely to be of greater benefit than other treatment options.  Final Result: Three 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: All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. All three 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: An enrollee has requested dental services for treatment of his medical condition. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Radiation therapy, as undergone by the patient is known to be associated with xerostomia or dryness of the mouth caused by damage to the salivary glands. The dental literature provides multiple modes to mitigate the increased risk of decay faced by patients with xerostomia. These modes of mitigation include but are not limited to use of sialagogues to increase salivary flow, topical fluorides to increase resistance, diligent home care and preventive care, and dietary adjustment.  With diligent care including these modalities patients with radiation-induced dry mouth are still at a high risk. However, the proposed dental services are not likely to address the patients condition as the deterioration demonstrated may cause restorations to fail. Therefore, given the limited likelihood of potential benefit, the requested dental services are not supported as medically necessary for treatment of the patients medical condition.  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 dentistry 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: An enrollee has requested Concerta for treatment of his behavioral health condition. Findings:  The physician reviewer found that there is no contraindication to the use of methylphenidate for reasons of cardiac disease or an eating disorder. In regards to concern about methylphenidate lowering the seizure threshold in this patient, the use of this combination is supported by expert opinion. The literature indicates that methylphenidate (MPH) is one of the most commonly prescribed medications to treat attention deficit hyperactivity disorder (ADHD). The literature further states Case reports have warned about new-onset seizures in patients treated with MPH, and drug-drug interactions between MPH and antiepileptic drugs as well as antidepressants. However, retrospective chart reviews, open-label trials and controlled trials of MPH in patients with epilepsy and ADHD have noted significant improvements in ADHD symptoms without an exacerbation of seizures or an adverse effect on antiepileptic drugs (AED) serum levels. Researchers also concluded children with epilepsy have a significant risk for problems with ADHD.  Clinical studies suggest a prevalence of 30% to 40%.  Inattention is more common than hyperactivity and impulsivity and treatment should include psychoeducational interventions and medication.  Stimulant drugs are safe and effective in children with epilepsy and currently are first-line agents for treatment of attention problems in this population.  Given the support above, the request for Concerta is clinically indicated for the 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 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 anesthesia services provided for a gastrointestinal endoscopic procedure for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  Colonoscopy and esophagogastroduodenoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care.  The medical evidence does not support the medical necessity of the services at issue in this clinical setting.  All told, anesthesia services provided during a gastrointestinal endoscopic procedure were not medically indicated for the 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 anesthesiology 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.