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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty for treatment of the enrollees asthma.  Findings:  2/3 of the physician reviewers found that although, bronchial thermoplasty has been U.S. Food and Drug Administration (FDA) approved for the treatment of severe persistent asthma, based on the review of current peer-reviewed literature, the quality of literature available is poor in regards to objective evidence of therapeutic benefits, as well as long-term safety and efficacy.  The majority of literature available shows only modest improvement in quality of life and lower rates of asthma exacerbation. The literature fails to show evidence that bronchial thermoplasty provides significant benefits in asthma control scores. The majority of literature also supports that additional research is needed to provide a better understanding with regards to its long-term safety and benefits as compared to other treatment options, as well as to clarify the role that bronchial thermoplasty plays in the management of severe asthma.  In sum, the requested bronchial thermoplasty is not likely to be superior over other treatment alternatives in this patients case.  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 internal medicine with sub-specialty certification in pulmonary 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in pulmonary 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in pulmonary 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing performed for evaluation of the enrollees glioblastoma multiforme. Findings:  2/3 of the physician reviewers found that the FoundationOne assay is a molecular assay that explores the mutations of an individuals cancer cells. The hope of course is that the assay will identify a specific mutation or target which could guide the clinician as to which chemotherapeutic agent would be useful in treatment.  However, at this time, there is a lack of convincing evidence that the assay adds to our decision making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the potential value of molecular profiling, none of which have been convincing as to the efficacy of these analyses. A randomized trial by colleagues did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Merely finding a mutation does not guarantee that a treatment directed at the mutation will produce a clinically meaningful response. All told, genetic testing performed was not likely to have been more efficacious than other methods of evaluating this patient.  Final Result: 2/3 of the 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: 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 home skilled nursing care for treatment of the enrollees cerebral palsy and impaired oral feedings. Findings:  The physician reviewer found that based upon a review of the information provided, the patient does not meet medical necessity criteria for home health nursing. The patient is not on mechanical ventilator and does not have a tracheostomy. She does not have poorly controlled seizures. The patients care needs are reportedly being met by the current available and trained caregivers, which includes her parents. In addition, the patients pulmonologist and pediatrician did not identify skilled nursing needs for the patient. As such, the request for home skilled nursing care is not 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 pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services provided during a colonoscopy for management of the enrollees pain during her colonoscopy procedure.  Findings:  The physician reviewer found that there is a lack of documentation of clinical findings that would have required monitored anesthesia care during this patients colonoscopy procedure. The patient was given an American Society of Anesthesiology (ASA) preoperative physical status classification score of 2. A low preoperative physical status classification score of 2 indicates that this patient did not require monitored anesthesia care. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the literature. For all these reasons, the anesthesia services provided during a colonoscopy were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for the treatment of this patient.  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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Relpax 20 mg for treatment of the enrollees chronic migraine. Findings:  The physician reviewer found that the patient has a history of chronic migraine and the standard treatment includes preventives such as amitriptyline, and abortives, such as triptans. The response to each triptan is patient specific, in terms of benefit and side effects. Parkinsons side effects are not typical with triptans. The records state that Parkinsons side effects were reported with a non-triptan medication containing isometheptene. Almotriptan is a reasonable abortive treatment for this patient. However, it unclear from the documentation provided that this was initiated with this patient. Only after a documented trial and failure with almotriptan, should Relpax be initiated. For these reasons, Relpax 20 mg 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 internal medicine with sub-specialty certification 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 authorization and coverage for Repatha Sureclick for treatment of the enrollee who has a history of coronary disease.Findings:  The physician reviewer found that based on the records provided the patient has known coronary disease, intolerance to some statin medications (Crestor and Lipitor), and current use of simvastatin 20 mg/day without a documented LDL level since start of simvastatin.  In this circumstance the medical records do not confirm that 20 mg is the highest tolerable dose of simvastatin and do not document an LDL level after being stable on simvastatin.  There is also no documented trial and failure of Zetia.  While Zetia, on average, may lower LDL from 15 to 25 percent, occasionally, more dramatic lowering occurs in some individuals. Outcomes have been demonstrated to be improved with the addition of Zetia. Moreover, in this patients case, there is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ovarian artery embolization for treatment of the enrollees pelvic pain and menorrhagia. Findings:  The physician reviewer found that this patient underwent UAE for fibroids, pressure symptoms, and menorrhagia. She did have on submucosal fibroid when she had the first imaging, but this resolved after the UAE, when only a small posterior myoma remained. As noted in the medical literature, predictors of a greater improvement in symptom score following the procedure include a presenting symptom of heavy menstrual bleeding rather than other symptoms, smaller leiomyoma size, and submucosal location. This patient no longer has a submucosal myoma, so it is unlikely that the residual small fibroid is causing her ongoing symptoms, or that ablating the fibroid would improve her clinical situation. She does have a bulky uterus, which is probably residual from the ablated fibroids but could also represent another condition, such as adenomyosis, which could be causing her ongoing symptoms and will not respond to a repeat ablation procedure. Overall, there is sparse literature available on ovarian artery embolization for treatment of fibroids. Embolizing the ovarian vessels can also impact the ovaries and cause premature menopause, which could create new issues for the patient. 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 obstetrics and gynecology 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 reimbursement and prospective authorization and coverage for residential treatment services for the treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that this patients substance use has been central to his daily routine and has been contributing to his significant impairment across multiple domains of functionality.  He began abusing drugs at the age of 10, which undoubtedly has compromised critical elements of psychological development such as identity formation.  Upon admission, he was addicted to multiple substances and was blacking out frequently.  He had difficulty holding down a job. He had no meaningful sober support network. The patient had previously failed outpatient drug treatment.  He also had co-occurring mental illnesses and a recent acute psychiatric hospitalization.  The patient was restless, agitated and anxious and had not completed his Suboxone taper.  The patient had a tense family session that evidenced a significantly strained support system. The patients appetite was suppressed, and his sleep was limited to three to five hours per night despite medication. The patient was experiencing anxiety, shakiness, flashbacks and poor concentration.  In sum, the services and setting were and are safe, appropriate and consistent with good practice. Additionally, the services provided were and are reasonably expected to improve the patients condition, prevent a more serious episode of illness and facilitate a seamless transition to comprehensive community-based programming.  Final Result: The reviewer determined that the services at issue were and 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 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 authorization and coverage for plantar hyperhidrosis surgery for treatment of the enrollees plantar hyperhidrosis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In recent years, lumbar sympathectomies have been proposed for treatment of patients with intractable plantar hyperhidrosis. To date, the amount of long-term, prospective evidence addressing the use of lumbar sympathectomy for the treatment of plantar hyperhidrosis is extremely limited. Questions about efficacy, side effects and long-term outcomes have yet to be answered.  Since a formal protocol/technique does not yet exist for this novel technique, the level at which surgeons perform the lumbar sympathectomy is controversial and may vary among institutions.  For this reason, higher rates of complications are associated with lumbar sympathectomies than alternative treatments for hyperhidrosis. At this time, the medical evidence addressing the use of lumbar sympathectomy is insufficient to allow an adequate evaluation of safety and efficacy.  All told, the requested plantar hyperhidrosis surgery is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested authorization and coverage for lumbar fusion for treatment of the enrollees lumbar stenosis. Findings:  The physician reviewer found that this patient presents with chronic back pain. He has had lower extremity pain, numbness and subjective weakness. On recent examination by his provider, there was no atrophy or weakness on individual muscle testing. He has had a history of a slapping left foot. The patients symptoms have not reportedly been evaluated with electromyography/nerve conduction velocity (EMG/NCV) testing nor has he had a Tinels sign on examination at the fibular head to rule out a peripheral cause of his symptoms. There is no documentation of failed conservative management with physical therapy addressing his back condition, injections, epidural steroid injections, or chiropractic treatment. He has not had a hip, knee, foot, ankle examination, sacroiliac joint examination, nor a vascular examination to rule out other possible causes of pain, numbness, and weakness. He has had ill-defined lower extremity symptoms without dermatomal/myotomal symptoms or findings consistent with a lumbar radiculopathy. He has an abnormal MRI scan at L4-5, but there is no correlation of his imaging with his clinical examination. Thus, the criteria for lumbar spinal fusion has not been met. There is no evidence of lumbar radiculopathy, spondylolisthesis with neurogenic claudication, and failure of conservative management in past six weeks to three months. Further, there is no motor weakness consistent with imaging findings, rapidly progressive neurologic findings that correlate with imaging, and other treasonable causes of pain have not been ruled out. Thus he fails to fulfill criteria for decompression/discectomy/fusion. As noted by a study, in the absence of deformity or instability, the inclusion of a fusion is not recommended.  Final Result: The reviewer determined that the requested surgery 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 neurological 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: An enrollee has requested bilateral hip replacement surgery sooner than three months for treatment of the enrollees hip pain. Findings:  The physician reviewer found that the current, evidence-based, medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. Criteria include exercise therapy with supervised physical therapy and/or home rehabilitation exercises and medications, which unless contraindicated, include non-steroidal anti-inflammatory drugs or steroid injections. Subjective findings should include limited range of motion, or night-time joint pain, or no pain relief with conservative care. Objective findings should include over 50 years of age and body mass index less than 35 kg/m2.  Additionally, imaging findings of osteoarthritis on standing x-rays or arthroscopy are required. This patient presents with a history of chronic bilateral hip pain, worsening over the past year. The severity of his pain was impacting his activities of daily living.  There were no specific hip examination findings documented.  There is imaging evidence of severe left hip and mild to moderate right hip osteoarthritis.  Conservative treatment was documented to include opioid pain medications and nonsteroidal anti-inflammatory drugs. Evidence-based medical guideline and peer-reviewed literature guidelines have been met to support the medical necessity of total hip replacement. The Health Plan anticipated scheduling bilateral total hip replacements in approximately three months, but the patient has requested surgery sooner due to pain.  However, there is no current documentation that the patients pain medication or other conservative treatment has failed to provide adequate pain management to support a request for sooner surgery. 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 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.