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

An enrollee has requested authorization and coverage for laparoscopic anti-reflux surgery utilizing LINX reflux management system. In this case, the persistence of symptoms and findings of esophagitis is suggestive of the development of Barretts esophagus. Persistence of these symptoms can result in complications of asthma including pneumonia and cardiac failure. Current data supports that medical therapies reduce acid production and do not correct the functional problem of lower esophageal sphincter incompetence. Surgical intervention can include fundoplication or magnetic sphincter augmentation with LINX. The procedures are comparable in reducing reflux, and have similar low complication rates. For these reasons, the requested laparoscopic anti-reflux surgery utilizing LINX reflux management system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested 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 reviewers 1, 2, and 3 are board certified in surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for CancerTYPE ID testing. Gene expression profiling (GEP) assays attempt to identify the tissue of origin in patients with occult primary cancers. The literature on GEP has focused more on establishing a tissue of origin than on determining whether such identification leads to better outcomes in patients. Thus, while there may be a diagnostic benefit with GEP, a clinical benefit has not been demonstrated in the peer-reviewed medical literature. Moreover, the National Comprehensive Cancer Network (NCCN) does not recommend tumor sequencing and gene signature profiling for patient management in this clinical setting. This patient has known metastatic breast cancer and her recent biopsy was consistent with this diagnosis. The standard of care is to biopsy new metastases as tumors evolve over time. Given these findings, the CancerTYPE ID testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in medical 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for the Cartiva implant procedure. The records provided for review document painful left-sided hallux rigidus and hallux valgus. From a surgical perspective, first metatarsophalangeal joint arthrodesis or first metatarsophalangeal joint metallic implant remain the longstanding surgical standards of care for hallux rigidus. Numerous studies have demonstrated that well-selected patients can benefit with first metatarsophalangeal joint arthrodesis and are able to continue with vigorous physical activity. Metallic implants for the base of the proximal phalanx and the head of the first metatarsal have been shown to be safe and effective for the treatment of painful hallux rigidus. The Cartiva implant is a novel first metatarsophalangeal joint implant. Studies show that this implant carries its own risks and complications, and has not been demonstrated to be more safe or effective than first metatarsophalangeal joint arthrodesis or a first metatarsophalangeal joint metallic implant. All told, the Cartiva implant procedure was 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in podiatry 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

The patient has requested reimbursement for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The patients composite score is consistent with medically monitored community based services, such as partial hospitalization program (PHP) level of care. Given these findings, the RTC services were not medically necessary for 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 psychiatry with expertise in addiction 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for the Oncotype DX-Prostate Cancer Assay. Tissue-based molecular biomarkers including the Oncotype DX-Prostate Cancer Assay may improve the accuracy of prognosis when added to standard clinical parameters. Current data suggests that the Oncotype DX-Prostate Cancer Assay might be helpful for patients with low Gleason score and high volume or those with high Gleason score and low volume. However, these genomic assays are only clinically useful when the results, considered as a whole with routine clinical factors, are likely to affect a clinical decision. This patient had low Gleason score and low volume disease. There is a lack of peer-reviewed medical literature supporting a role for the Oncotype DX-Prostate Cancer Assay for patients with low Gleason score and low volume disease. Therefore, the Oncotype DX-Prostate Cancer Assay was not likely to be more beneficial for evaluation of the patients medical Final Result: 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 reviewers 1, 2, and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of the patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS guideline, RTC services were and are medically necessary for treatment of this patient. These findings give the patient a composite score which is consistent with medically monitored community based services. All told, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 with subspecialty certification in child and adolescent 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for axillary reverse mapping (CPT 38900). Following axillary lymph node dissection for breast cancer, some patients will develop lymphedema of the arm due to disruption of the lymphatic channels during the axillary surgery. Clinical trials have demonstrated improvement with axillary reverse mapping to visualize and preserve lymphatics. This patient has magnetic resonance imaging (MRI) and physical examination findings consistent with matted axillary lymph nodes. Given the support in the medical literature, the axillary reverse mapping (CPT 38900) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the axillary reverse mapping (CPT 38900) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested 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 reviewers 1, 2, and 3 are board certified in surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for the medication Dupixent. In this patients case, the diagnosis is not clear. The records suggest that the patient has contact dermatitis that is poorly controlled, and this diagnosis has not been addressed fully in the enclosed documentation. Avoidance of the contact allergens would be the first step, and then non-pharmacologic interventions and counseling on this would be medically appropriate. The records do not clearly demonstrate that the patient has atopic dermatitis, and Dupixent would be more appropriate for atopic dermatitis, not contact dermatitis. Therefore, the requested medication Dupixent is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

:  The enrollee requested coverage for the medication Entyvio. The enrollee has been diagnosed with ulcerative colitis at a young age. The patient was started on treatment with Entyvio (generic name: vedolizumab) every eight weeks and reported significant improvement. Laboratory testing of the Entyvio level in his blood was done and the report showed the level was low. A colonoscopy showed improvement in his ulcerative colitis from severe to moderate, but no resolution of ulceration and inflammation. The patient reported he still had symptoms. His physician has recommended increasing the patients dose frequency from every eight weeks to every six weeks. The medical literature has shown that dose intensification restored responsiveness in more than half of those patients and increasing dose frequency is useful if patients are not responding sufficiently to an eight-week dosing interval.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient had been diagnosed with pes planus. The provider noted a diagnosis of patellofemoral pain syndrome of both knees. The patient was noted to have recovered from bilateral talar contusions. The provider noted that the patient was able to resume physical education activities, although she had been avoiding high impact sporting activities. The patient reported fatigue in her calves and inability to tolerate dress shoes for prolonged periods of time, as over-the-counter orthotics do not fit. Physical examination findings included bilateral gastrocnemius equinus and severe bilateral pes planus. In the independent medical review (IMR) application, the parent noted that the patient had tried and failed over-the-counter orthotics. The patients parent has requested authorization and coverage for bilateral custom foot orthotics (HCPCS L3020). The Health Plan denied the request and reported the requested devices are not medically necessary for the treatment of this patient. At issue in this case is whether bilateral custom foot orthotics (HCPCS L3020) are medically necessary for the treatment of the patients medical condition. A research reported Careful casting is critical for pes planus foot architecture. A foam impression may prove sufficient if the goal is merely to support and accommodate the present foot structure. However, custom orthosis correction is usually desirable in order to prevent degenerative mechanics and inefficient gait. Suspension casting is preferred. In this case, the patient has been diagnosed with pes planus, which has caused talar contusions and patellofemoral knee pain bilaterally. It was also noted the patient has tried over-the-counter orthotics, which failed to alleviate her pain. The medical evidence supports the requested devices in this clinical setting. Therefore, bilateral custom foot orthotics (HCPCS L3020) are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested devices 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 D.P.M., 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for dupilumab (Dupixent) 300 mg/2 ml and injections of 600 mg injected subcutaneously on day one and/or injections of 300 mg every other week. The patient was diagnosed with dermatitis. Physical examination findings included hyperpigmented plaques on the posterior proximal interphalangeal areas of the hands. Erythematous scaly plaques were noted on the digits of both hands. Researchers noted, dupilumab is the first U.S. Food and Drug Administration (FDA) approved therapy for moderate-to-severe atopic dermatitis. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, dupilumab (Dupixent) 300 mg/2 ml and injections of 600 mg injected subcutaneously on day one and/or injections of 300 mg every other week are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Adderall 10 mg tablet as needed and Adderall XR 25 mg capsules ER 24 hour, two capsules every day in the morning. The patient has been diagnosed with attention deficit/hyperactivity disorder (ADHD). The provider noted only brand name Adderall was effective for the patient as she has tried and failed the generic formulation, with no significant response or benefit. The patient was noted to have experienced dizziness and headache with generic Adderall. Researchers have reported that generic substitution may give rise to compliance issues and may not be as economically profitable as once hoped. Switching between formulations should be done on a case-by-case basis, in collaboration with the patient and with close monitoring. The medical evidence supports the requested medications in this clinical setting. Therefore, Adderall 10 mg tablet as needed and Adderall XR 25 mg capsules ER 24 hour, two capsules every day in the morning are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Otezla 30 mg tablets. ESTEEM 1 is the first phase III study confirming the efficacy of apremilast in psoriasis. Apremilast demonstrated significant improvements in mean percentage change in psoriasis area and severity index (PASI) scores and in pruritus. PASI response was maintained over 52 weeks with continued apremilast treatment. In addition, apremilast demonstrated improvements in nail and scalp psoriasis, both difficult-to-treat forms of psoriasis. In this case, the patient has chronic plaque psoriasis that requires systemic treatment. There is sufficient support for the requested medication in this clinical setting. Therefore, Otezla 30 mg tablets are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for surgery to straighten the right hallux (big toe). The smoking of cigarettes can slow down and/or reduce the ability of bones to heal after surgery. Procedures involving arthrodesis, fracture open reduction internal fixation, and plastic surgery have been associated with negative outcomes in smokers. Researchers noted that the osteotomy of a smoker took 1.73 times longer to reach radiographic bone consolidation than that of a nonsmoker. The patient has pain below the second metatarsophalangeal joint. Further documentation and x-ray evaluation has revealed a dorsal contracture at the second metatarsophalangeal joint with elevation of the second digit. In this patients case, records reflect that the patients bunion must be corrected in order to allow for the lowering of the second digit and alleviation of pain below the second metatarsophalangeal joint. While the patient is a known smoker, the requested surgery to correct the patients painful foot is medically reasonable and necessary. Therefore, the requested surgery to straighten the right hallux (big toe) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 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.