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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for hyperthermia treatment; hyperthermia superficial; set radiation therapy field; and radiation treatment management times five, and 30 additional treatments including hyperthermia treatment; hyperthermia superficial; set radiation therapy field; and radiation treatment management times five. There is a paucity of high quality studies demonstrating the safety and efficacy of hyperthermia as compared to the standard of care consisting of chemoradiotherapy or infusion bacillus Calmette-Guerin (BCG) in the treatment of bladder cancer. One study examining the role of hyperthermia concluded that, given the high rate of severe side-effects leading to treatment discontinuation, as well as the limited tumor response, thermochemotherapy should be offered only in highly selected cases of recurrent non-muscle-invasive bladder cancer. In addition, the National Comprehensive Cancer Network (NCCN) guidelines do not support hyperthermia for the treatment of bladder cancer. All told, hyperthermia treatment; hyperthermia superficial; set radiation therapy field; and radiation treatment management times five, and 30 additional treatments including hyperthermia treatment; hyperthermia superficial; set radiation therapy field; and radiation treatment management times five, were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found hyperthermia treatment; hyperthermia superficial; set radiation therapy field; and radiation treatment management times five received and 30 additional treatments including hyperthermia treatment; hyperthermia superficial; set radiation therapy field; and radiation treatment management times five were not and 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 services at issue were not and are not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plans denial should upheld. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for septorhinoplasty for a deviated nasal septum, causing complaints of breathing problems; allergic rhinitis, and an undesirable cosmetic appearance.  She has enlarged inferior turbinates, a small dorsal hump and mild deviation of the dorsum.  A progress note from a head and neck plastic surgeon stated a septoplasty and inferior turbinate reduction is a reasonable option for resolving the enrollees breathing issues. The surgeon advised a nose-straightening procedure would be a very complex surgery; he could not completely or perfectly straighten her nose.  The enrollee also desired dorsal hump reduction. The record indicates the enrollees septum is deviated to the left.  However, there is insufficient evidence in the record in regard to diminished nasal airflow, breathing difficulties. The medical literature identifies numerous methods for evaluating the nasal airway, including objective methods and validated patient questionnaires. However, the record does not include evidence of the use of these objective assessments to determine the presence of clinically significant nasal obstruction in this enrollee to assess whether the enrollee had a clinically significant nasal obstruction. The record does not support the medical necessity of a septorhinoplasty. The alleged abnormality does not constitute an abnormal structure of the body, as nasal septums are almost universally asymmetrical.  The photograph of the enrollee does not show any gross deformity of her nose or an abnormal appearance and would not result in substantiative change. The surgery is not being performed to improve function, as there is no objective evidence of abnormal function in this case. The clinical examination indicates there is a small dorsal hump and mild deviation of the dorsum: convexity of the dorsum of the left, concavity mid third of nose on the right, which does not support the surgery providing more than a minimal improvement in the appearance of the enrollee and is not reconstructive in nature.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for upper endoscopy.The American Gastroenterological Association (AGA) and the American Society of GI Endoscopy (ASGE) recommend that patients who have Barretts esophagus without dysplasia undergo endoscopic surveillance every 3 to 5 years, with 4-quadrant biopsies taken every 2 cm with white-light endoscopy. The AGA further states that the preponderance of evidence, virtually all derived from retrospective or poorly controlled studies, suggests that endoscopic surveillance can reduce mortality from esophageal adenocarcinoma through the early detection of treatable cancers when attention is paid to recommended biopsy techniques. In this case, the patient had an upper GI endoscopy performed, and the present request is for upper endoscopy approximately two and a half years later. The request for endoscopy at this time is based upon a family history of GI neoplasm involving two third-degree relatives (cousins). This family history does not, however, constitute extenuating circumstances that would warrant upper endoscopy surveillance sooner than every 3 to 5 years. Accordingly, the requested upper endoscopy is not medically necessary for the patients medical condition at this time.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld.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: An enrollee has requested authorization and coverage for Nerlynx (neratinib). This patient had residual disease after neoadjuvant chemotherapy for an estrogen receptor negative, progesterone receptor negative, HER2 positive breast cancer and is considered high risk for recurrence. She was treated with adjuvant trastuzumab and pertuzumab. Nerlynx has been approved by the U.S. Food and Drug Administration for extended adjuvant treatment of early stage HER2 overexpressed/amplified breast cancer following adjuvant trastuzumab-based therapy. The National Comprehensive Cancer Network guidelines recommend consideration of extended adjuvant neratinib following adjuvant trastuzumab-containing therapy for patients with hormone receptor positive, HER2 positive disease with a perceived high risk of recurrence. The study leading to approval included hormone receptor negative cancers, but greater efficacy was seen in patients with hormone receptor positive disease. There is a lack of data on the safety or efficacy of neratinib in patients whose adjuvant therapy included pertuzumab, and significant diarrhea has been a problem in patients receiving neratinib after trastuzumab-based therapies without pertuzumab. There is a lack of support for the requested medication in this clinical setting. Therefore, Nerlynx (neratinib) 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.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for clonazepam 0.5 mg. Medical literature notes that benzodiazepines with an intermediate to long onset of action such as clonazepam might have less potential for abuse and less risk of rebound and thus helpful for chronic management of GAD. One study reported that clonazepam can be successfully discontinued without any major withdrawal symptoms if the dose is reduced gradually. The study focused on patients who have been treated with clonazepam for at least three years. This patient has been on the medication for many years. Thus, she requires a slow taper and sudden discontinuation of the medication is not recommended without a plan to taper and/or an alternative medication. The requested treatment is appropriate to treat the patients condition and sudden discontinuation could cause serious side effects. All told, clonazepam 0.5 mg 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Zolgensma. Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disorder characterized by degeneration of spinal motor neurons (Kolb and Kissel). SMA is caused by low levels of the survival motor neuron (SMN) protein due to deletions or mutations of the SMN1 gene. SMA results in profound weakness in the limbs and the respiratory muscles. An almost identical gene, SMN2 is present on the same chromosome and produces a smaller, truncated protein. The number of copies of the SMN2 gene in the patient is a major factor in the severity of disease. Zolgensma is indicated for the treatment of patients less than two years of age with SMA with bi-allelic mutations in the survival motor neuron 1 (SMN1) gene. Currently, the peer-reviewed published medical literature supports a clinical role of Zolgensma for infantile-onset or SMA type 1, and pre-symptomatic patients with a diagnosis of SMA and less than three copies of SMN2 gene. There are ongoing clinical trials on other indications for Zolgensma, but no available published data to support an indication for patients with more than two copies of SMN2. This patient has three copies of the SMN2 gene, which does not meet the current criteria for treatment with Zolgensma.  All told, Zolgensma is not medically necessary for 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. Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with special qualification in child neurology 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 the patient has requested authorization and coverage for direct 1:1 applied behavior analysis (ABA) and ABA supervision by a BCBA. This patients treatment plan covers 21 active treatment goals, four problem behavior areas, and two parent-training goals. These goals are being addressed in the school and clinic settings. With the requested treatment plan, this allows each goal to be addressed for approximately 90 minutes per week, or less when the patient displays problem behaviors. Combined, the patient's problem behaviors occur dozens of times per day. The problem behaviors pose potential harm to the patient and others. Thus, the requested level of support does meet the comprehensive level of treatment. The BACB outlines the provision of comprehensive treatment as subsequently increased or decreased based on the clients response to treatment and current needs. Hours may be increased to more efficiently reach treatment goals. Decreases in hours of therapy per week typically occur when a client has met a majority of the treatment goals and is moving toward discharge. While this patient has made some progress, his problem behaviors have almost tripled since baseline.  While the patients scores have improved in socialization and motor skills, the remainder of the scores are unchanged or worse. Specifically, all scores are between one and three standard deviations below the mean, and the age equivalents are approximately three years, or more, from the patients age.  Based on the presenting information, the patient is not maintaining at the current level and an increase in ABA treatment intensity is warranted. Research supports higher treatment intensity for better outcomes for children on the autism spectrum.  iven these findings, direct 1:1 applied behavior analysis (ABA) and ABA supervision by a BCBA 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 a licensed B.C.B.A, board certified in psychology, 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 was diagnosed with left knee osteoarthritis. In December of 2018, the provider noted a left knee x-ray revealed narrowing of the left knee medial joint space that had progressed compared to previous x-rays. The patient received Orthovisc injections to the left knee in June and July 2018. The provider noted prior Orthovisc injections provided significant pain relief. Physical examination findings included tenderness to palpation over the left knee lateral joint line and lateral patella. A left knee steroid injection was administered in July of 2019. The patient has requested authorization and coverage for Orthovisc injections in the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections in the left knee are medically necessary for the treatment of the patients medical condition. Review of current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is not known which individuals will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by a study  found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history benefit from prior left knee viscosupplementation injections. Furthermore, the options are limited, with the alternative being a total knee arthroplasty. Medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in the left knee are medically necessary for the 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 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 enrollee is requesting authorization and coverage for Supartz, for history of arthritic left knee pain.  A magnetic resonance of the left lower extremity joint without contrast was suggestive of degenerative osteoarthritis, radial tear at the junction of posterior horn with posterior root of the medial meniscus, sprain pattern without tear, and moderate to large joint effusion with a leaking popliteal cyst.  She received a Depo-Medrol injection in the left knee and reported minimal relief. Her orthopedist prescribed Supartz. A magnetic resonance imaging report of the left knee revealed high grade loss of articular cartilage with subarticular fibro-osseous changes and stress marrow edema medial and patellofemoral compartments. These findings suggest degenerative osteoarthritis. On follow up evaluation for left knee pain with her orthopedist, physical examination of the left knee revealed no increased pain with passive range of motion. Although, the enrollee has positive findings on MRI and is diagnosed with osteoarthritis, there is no evidence in the record she has not responded adequately to conservative treatments, such as exercise, and non-steroidal anti-inflammatory drugs. The enrollee did try corticosteroids with minimal relief, but there is no support to show the other conservative treatment options have been tried and failed. Review of the literature indicates several clinical trials have been developing many hyaluronic acid (HA) preparations and investigating their efficacy and safety. Although many studies have demonstrated the use of intra-articular HA injection would be a beneficial, non-surgical option for osteoarthritis and may delay the need for joint replacement, there is an ongoing controversy over the clinical effectiveness and sustainability of intra-articular injection of HA for OA patients. It has been demonstrated  there is not any significant difference between the intra-articular injection of HA and injection of physiological saline in patients with knee OA. The efficacy of HA injections for knee OA remains disputed with meta-analyses and societal clinical guidelines drawing different conclusions. A recently published best-evidence systematic review concluded that available data did not support the routine use of HA for knee osteoarthritis. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic sports medicine and orthopedics 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for laboratory testing. The enrollee has osteoarthritis, hypothyroidism, mixed hyperlipidemia, nocturia, and erectile dysfunction (ED).  An internal medicine note indicated enrollee complaints of ongoing pain in the right knee and bilateral shoulders. Examination demonstrated unremarkable vital signs but a body mass index (BMI) of 32.  Due to his age and gender, the physician believed he needed a more complete cardiovascular evaluation. His diagnoses of ED, presence of abdominal/visceral fat, and hypothyroidism raised his risk for cardiovascular disease.  The enrollee is currently on Crestor, but did not have complete knowledge of his cardiovascular risk. Laboratory testing was performed through a specialty lab and The Treatment Consideration Summary included lifestyle and dietary modification, statins, ezetimibe, niacin, fibrates, omega-3 fatty acids, and soluble fiber supplements. The use of advanced lipid testing, including particle analysis and genetic testing for predisposition for statin myalgias, is neither standard-of-care nor justified based on well-designed clinical research outcome studies.  Conventional lipid testing is recommended by professional societies for cardiovascular risk assessment. This approach would have represented current and contemporary standard of care for this enrollee with hyperlipidemia.  Novel lipid testing strategies have not been proven to offer actionable clinical benefit with definitive improved outcomes when compared to conventional lipid analysis. The clinical documentation does not reveal assessment findings to support the testing panel performed on this enrollee.  Final Result: Three of the three reviewers determined that the requested services were not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in cardiovascular disease 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.