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 for the Foundation One test provided for evaluation of the enrollees non-small cell lung cancer. Findings:  2/3 of the physician reviewers found that the utility of the Foundation One testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as Foundation One, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions on clinical utility. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the Foundation One test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar/sacral transforaminal epidural for treatment of the enrollee, who has a history of pain to his thoracic spine, lower back, testicular pain and bilateral legs, front and back.Findings:  The physician reviewer found that the submitted clinical documentation, the medical necessity of the requested lumbar/sacral transforaminal epidural has not been established. In this patients case, while the requesting provider noted that the patient went to physical therapy, in a telephone note instead of a regular office visit note, the physical therapy notation was not documented to be for any specific length of time and it is not corroborated with the medical records. This is part of the recommendation of having active exercise with the physical therapy. The literature does support that physical therapy, independent of an epidural, can give a patient lasting results. Moreover, the patient does not have any recent physical examination findings, electrodiagnostic or imaging studies supporting a diagnosis of lumbar radiculopathy involving the L5 nerve. Instead, the examination supports other diagnoses. Chronic testicular pain due to radiculopathy is noted to be usually at a higher level in the back than the L5 nerve. Furthermore, there are other treatment options as well as medications for low back pain, thought to be radicular, that have not been noted or performed. Final Result: The reviewer determined that the requested service 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 authorization and coverage for occipital nerve block for treatment of the enrollee who has a history of migraine headache. Findings:  2/3 of the physician reviewers found that migraine is commonly associated with pain in the neck, and back of the head, in as many as three out of four people. There are many treatment options for people with migraines, including acute medications such as sumatriptan, and a wide variety of preventative medications can also be used. Nerve blocks are widely accepted in the headache treatment community as potentially beneficial. They are used for acute treatment of acute headache, as well as preventively. Studies have generally shown advantage to the use of steroids in combination with anesthetic in the context of cluster headache. Nerve blocks are generally accepted as safe, though as with any procedure, there can be potential complications. Per the records, she has had benefit from prior occipital block.  However, the documentation does not indicate a history of prior medication use, nor the specific purpose for which nerve block was applied.  The documentation does not support that blocks are more beneficial than standard treatment, as there is no indication of what prior treatments have been provided and the results thereof. As such, the medical records do not support that occipital nerve block is likely to be more effective than other methods for the treatment of this the patients migraine headache condition.  Final Result: 2/3 of 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 reviewer number one is board certified in 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.Physician reviewer number two is board certified in 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.Physician reviewer number three is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program (PHP) services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that Based on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment than PHP level of care. The patients risk of harm score is two (2), a low risk of harm. The patient has no history of suicidal ideation or suicide attempts. The patients functional status score is three (3), moderate impairment. The patient has had conflicts with her boyfriend due to drinking. Her boyfriend would drink alcohol and when the patient received treatment and committed to sobriety, the relationship ended. The patient did have a supportive family. The patients alcohol use was causing impairment in the patients ability to function in her daily life as she would isolate herself. The patients medical, addictive, psychiatric co-morbidity is three (3), significant co-morbidity. The patient has a co-morbidity of alcohol use disorder. She continues to use alcohol despite negative consequences. The patient has anxiety regarding financial stressors due to impulse spending. The patients recovery environment score is two (2), mildly stressful environment. The patient has conflicts with her boyfriend. However, the patients family is supportive. The patients level of support is two (2), supportive environment. The patients family is supportive. The patients treatment history score is two (2), significant response to treatment. The patient had limited prior alcohol use treatment. She had a good response to treatment at the residential and PHP level of care. She was psychiatrically and medically stable. Her engagement and recovery status score is two (2), positive engagement and recovery. The patient is motivated for recovery and is compliant with treatment recommendations. Based on these criteria, the patient has a total score of 16, which would meet criteria for treatment in a less restrictive environment. Therefore, the PHP services provided were not medically necessary for treatment of the patients medical condition.  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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the hyperbaric oxygen therapy for treatment of the enrollees left ear sudden idiopathic hearing loss. Findings:  2/3 of the physician reviewers found that the records indicate that this patient presented with sudden hearing loss. The provider recommended hyperbaric oxygen therapy for the patient. The evidence for hyperbaric oxygen therapy for treating sudden hearing loss is limited. In one study, there was only 9.6% chance of improvement with hyperbaric oxygen therapy treatment. Another controlled study found benefit only in patients treated in the first four weeks. This patient was treated with hyperbaric oxygen therapy six weeks after initial presentation. All told, there is a paucity of data demonstrating that the hyperbaric oxygen therapy provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the service at issue was 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 reviewer number one is board certified in otolaryngology 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.Physician reviewer number two is board certified in otolaryngology 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.Physician reviewer number three is board certified in otolaryngology 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 Doppler-guided transanal hemorrhoidal dearterialization for treatment of the enrollee who has a history of hemorrhoids. Findings:  2/3 of the physician reviewers found that THD is a technique used by colorectal surgeons as a treatment option for hemorrhoids. Multiple studies in support of THD have been recently published. For example, a recent systematic review and meta-analysis was published regarding the clinical outcomes and effectiveness of surgical treatments for hemorrhoids.  The review included 98 studies with 11 treatments for hemorrhoids and 7,827 patients.  The authors concluded that THD was associated with less postoperative bleeding and therefore, less emergency reoperations as well as decreased postoperative complications, shorter operative time, and decreased pain.  The authors concluded that the low cost of THD, low complication rate, shorter operating time and decreased levels of postoperative pain, but higher recurrence rate, may suggest THD as a safe, quick and easy initial surgical option.   In another study the authors concluded that THD is a safe and effective treatment of hemorrhoid disease. As such, the current medical evidence supports the efficacy of this treatment option for the treatment of hemorrhoids in patients who have exhausted conventional nonsurgical options. All told, Doppler-guided transanal hemorrhoidal dearterialization performed was likely to have been of greater benefit than other treatment modalities for the treatment of this patients hemorrhoidal disease.  Final Result: 2/3 of 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 reviewer number one is board certified in surgery with sub-specialty certification in colon and rectal 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.Physician reviewer number two is board certified in surgery with sub-specialty certification in colon and rectal 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.Physician reviewer number three is board certified in surgery with sub-specialty certification in colon and rectal 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 reimbursement for extracorporeal shock wave therapy performed for the enrollees chronic recalcitrant plantar fasciitis. Findings:  The 3 physician reviewers found that there is a lack of medical literature supporting the services at issue in this clinical setting. Colleagues performed a systematic review and meta-analysis to assess the efficacy of ESWT. The authors concluded that The efficacy of low-intensity ESWT is worthy of recognition. The short-term pain relief and functional outcomes of this treatment are satisfactory. However, owing to the lack of a long-term follow-up, its long-term efficacy remains unknown. Given that the lack of evidence supporting the efficacy of ESWT for the treatment of plantar fasciitis, the ESWT performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the services at issue were 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 reviewer number one is board certified in podiatry 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.Physician reviewer number two is board certified in podiatry 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.Physician reviewer number three is board certified in podiatry 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 Stretta procedure for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that there is inadequate clinical data from evidence based guidelines and published well-constructed randomized clinical studies to conclude that Stretta results in long-term improved clinical outcomes for GERD. A systematic review to evaluate evidence on the efficacy of Stretta for the management of gastroesophageal reflux did not show any benefit of Stretta over sham therapy. Specifically, data on the mean percentage of time that pH was less than 4 over 24 hours showed no significant benefit of Stretta over sham therapy. In addition to lack of efficacy, adverse events reported to the U.S. Food and Drug Administration (FDA) include pneumonia, gastroparesis, esophageal perforation, and cardiac arrest. Support for the Stretta procedure among national medical societies varies and the most recent American College of Gastroenterology guidelines on GERD reported that current endoscopic therapycannot be recommended as an alternative to medical or traditional surgical therapy. For these reasons, Stretta procedure is not supported as medically necessary for the treatment of this patients GERD. Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Urolift for treatment of the enrollees enlarged prostate with urinary obstruction. Findings:  2/3 of the physician reviewers found that Urolift is a novel, minimally invasive approach to treating benign prostatic hyperplasia that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials, including prospective, sham-controlled, randomized studies, have shown that Urolift is safe and effective in relieving lower urinary tract symptoms due to benign prostatic hyperplasia without significantly compromising sexual function. Compared with transurethral resection of the prostate and photoselective vaporization, Urolift is minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time.  In sum, Urolift is likely to be of greater benefit for the treatment of this patient than other available treatment options. Final Result: 2/3 of the reviewers determined that the requested services are 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.