Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sacroiliac (SI) joint injection. Findings: In this case, the providers notes state that the patient has low back pain radiating into the right lower extremity consistent with the nerve distribution of L4, L5, and S1. A magnetic resonance imaging (MRI) confirms narrowing of the neural foramina at L4-5, and CT demonstrated disc protrusions at L 4-5 and L5-S1, which are consistent with the patients symptoms. The providers note state the straight leg test was positive at 45 degrees, which is suggestive of a lumbar radicular pain pattern and not an SI joint pain pattern. According to the American Society of Interventional Pain Physicians (ASIPP) guidelines, documentation should include three separate provocative tests on the SI joint itself to establish a higher diagnostic probability that the SI joint is the pain generator. The notes state the Patricks test was positive. However, the records do not report that the provider performed a Gaenslens test or other SI joint provocation tests. The providers diagnostic impression is lumbar radiculopathy and not an SI-joint related cause for back pain that does not travel down the leg. A review by Thawrani and colleagues outlines that an SI joint injection is indicated for suspected SI joint related pain and not lumbar radicular pain. This patient has lumbar radicular pain. Based on the medical records for review and the current evidence based medical literature, the requested SI joint injection to treat lumbar radicular pain is not medically necessary.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 anesthesiology with subspecialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the chemotherapy medication cabazitaxel.The submitted documentation supports that the requested medication is medically necessary. Chemotherapy is certainly appropriate in prostate cancer patients who have become refractory to hormonal therapies. The most commonly used drug is taxotere. In this case, however, the patient has an unusual autonomic nerve dysfunction, aphonia. Accordingly, his doctor is concerned with possible neurotoxicity from the taxotere. Cabazitaxel is a taxane drug, similar to taxotere, with equivalent efficacy to taxotere, but with less potential for neurotoxicity. Cabazitaxel is generally used once taxotere fails, but it is a reasonable first choice in this particular patient, because of the concern for neurotoxicity. Accordingly, under these circumstances, the requested medication, cabazitaxel, is medically necessary for treatment of the patients medical condition.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 internal medicine, with subspecialty 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:  The enrollees parent has requested authorization and coverage for bilateral custom arch support orthotics. A pediatrician saw the enrollee for pain in his feet for which he has tried different shoes. The pediatrician prescribed custom arch support orthotics. There is insufficient evidence in the medical record of radiographs or imaging results, so the degree of deformity is unknown. The enrollee was advised to wear arch supports and return if they failed to improve his symptoms. According to the medical literature, in enrollees with painful juvenile flexible flat feet, generic foot orthoses are sufficient, unless the enrollee presents with juvenile arthritis. Many different foot conditions can occur in the juvenile population, so it is imperative to determine the underlying cause of the foot pain prior to ordering custom orthotics. In cases of flatfoot deformity in the presence of chronic juvenile arthritis, very few studies show that the pain is reduced with the use of functional custom orthotics. Finally, there is insufficient documentation in the record of the prior use of over-the-counter orthotics that failed at symptom relief for this enrollee.  Studies have shown there is no benefit to custom orthotics over the generic orthotics, in these cases. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested reimbursement for residential treatment center (RTC) services. Findings:  The physician reviewer found that the requested service is not medically necessary for the treatment of the enrollees medical condition. He was admitted to a RTC due to the social consequences of his addictions; legal charges, unemployment and homelessness. He has a history of substance and alcohol abuse. He initially received detoxification services at the facility and then transitioned to the regular residential program. The enrollee was very motivated for treatment. His goals included improving his communication and interpersonal skills, receiving education regarding substance abuse, improving his health, and preventing relapse. He participated in individual and group therapy and received medication management.  He stepped down to a partial hospitalization program (PHP) level of care. Review of the record indicates the enrollee felt satisfied with his life but not with his relationships. He denied ever been diagnosed with mental health disorders or taking any psychotropic medications. He reports feeling anxious and hopeless because of his substance use. He was very motivated to recover. His alcohol and substance abuse withdrawal score remained low throughout his stay. The enrollees composite score is 19, which correlates with community outpatient services. This enrollee does not meet the RTC level of care requirements.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 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for Oncotype DX Genomic Prostate Score testing for prostate cancer.  The enrollee was diagnosed with prostate cancer.  Findings:  The physician reviewer found that his prostate-specific antigen (PSA) value was 3.2, which was up from 2.8. He had an episode of bright red blood in his urine, reported urinary frequency at a rate of every three hours and one to two episodes of nocturia. A biopsy performed showed adenocarcinoma involving one out of twelve cores. The sample tested as a Gleason grade 3+4. It showed demonstrated tumor involvement of 5% in the left lateral base. Gleason pattern 4 comprised 10% of the tumor in the left lateral base.  He underwent Oncotype DX Genomic Prostate Score testing. The result was classified as unfavorable intermediate risk. Review of the literature indicates while tissue based genomic biomarkers tests, such as Oncotype DX Genomic Prostate Score may offer an additional measure of risk stratification in patients with prostate cancer, this type of testing has not demonstrated a clear role in disease surveillance. Studies have not confirmed a clinical benefit to this type of testing. Other studies suggest it may have future utility, but more research is necessary to support its use.Final Result: Three of the three reviewers determined that the requested services are 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 urology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for actigraphy testing. Findings:  Three of the three physician reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition.  The enrollee is diagnosed with non-24-hour circadian rhythm disorder. He was evaluated at a sleep center and results showed an Epworth sleepiness score of 0, insomnia scale of 18, fatigue scale of 29, sleep paralysis frequency score of 5, and the reduced Morningness-Eveningness questionnaire (rMEQ) score is 14. His bedtime and wake time is delayed by one hour each day and sleep-onset latency is less than 20 minutes. His reported sleep time is eight hours. He is unrefreshed upon wakening and has excessive daytime sleepiness. The sleep center physician ordered polysomnography with seizure montage and actigraphy to objectively assess the enrollees circadian rhythm. Actigraphy devices have FDA 510(K) clearance for use as a medical device. However, contribution of actigraphy to diagnoses of circadian rhythm sleep disorders (CRSD) is limited. Practice parameters from the medical literature have determined that recommendations for this procedure are low-level, as their benefit for the evaluation of circadian rhythms has yet to be determined nor has this technique been demonstrated to provide more benefit than other methods of evaluation, such as sleep diaries. The limited credible literature for CRSD precludes the ability to make conclusions on the efficacy of actigraphy when compared to (patient completed) sleep logs/sleep diaries.  Current literature supports that gold standards for measurement of sleep and wake cycles are polysomnography and the multiple sleep latency test. Actigraphy is a useful alternative if a polysomnogram cannot be completed and is particularly useful when recording of sleep and wake cannot be determined by sleep diaries or observation. In the clinical records submitted for review, there is insufficient evidence of inability to record sleep and wake cycles or obtain information needed for treatment using more traditional methods. The utility of actigraphy to assess circadian rhythm disorders has not been proven. Thus, there are few data to support its use and given the limitations of actigraphy it is not likely the results of actigraphy would impact the enrollees treatment plan. Final Result: Three of the three reviewers determined that the requested services are 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 sleep medicine and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for abdominoplasty. The enrollee underwent gastric sleeve surgery and now reports she has excess abdominal skin with recurrent umbilical infections. She presented to a plastic surgeon for a complaint of excess abdominal skin. Findings:  The physician reviewer found that the surgeon noted she has a small panniculus that is not to the degree that a panniculectomy is medically indicated.  At a visit with her family practice physician, she had complaints of pain and a bad odor at the umbilicus. Antibiotics were ordered for possible umbilical cellulitis. At a different plastic surgeon, she indicated she had intermittent rashes and infections around her umbilicus for three years with a constant odor; affecting her quality of life. On examination, she had minimal dermatitis under her pannus. The pannus did not extend to the groin. There was a moderate amount of overhanging skin above the umbilicus. The surgeon indicated she was not eligible for a panniculectomy but would benefit from a full abdominoplasty to address the upper abdominal skin overhang. Subsequently, her family practice physician prescribed antibiotics for the same complaints of pain and irritation to the area and was prescribed more antibiotics.The record indicates enrollee complaints of infection, intermittent rashes and foul odor of her umbilicus treated with antibiotics. However, the record does not provide sufficient evidence of ongoing infection despite the noted antibiotic use. The enrollees ability to function is not impaired by her condition. The record does not provide sufficient evidence that abdominoplasty is medically necessary. The alleged abnormality, upper abdominal skin overhang, does not constitute an abnormal structure of the enrollees body. The surgery will not create a normal appearance to the extent possible and will not provide more than a minimal improvement in the enrollees appearance.  Abdominoplasty is a contouring procedure 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 plastic and reconstructive 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:  The enrollees parent is requesting authorization and coverage for the prescription medication Genotropin for idiopathic short stature and mild constitutional delay with no chronic medical problems.  Findings:  The physician reviewer found that the enrollees pediatrician initiated a work-up for short stature. Growth records show that her heights were at, or slightly below, the 3rd percentile since age three and a half and her weights were between the 15th and 45th percentile. Her height was 2.39 standard deviations below the mean and her growth velocity was 3.84 cm per year.  Growth hormone therapy was started at age eleven. Nutropin was tried initially, but the enrollee experienced discomfort with injections and this was changed to Genotropin.  While on growth hormone therapy, her growth velocity is 7.44 cm per year.  According to the record, the enrollee experiences stinging and discomfort with Nutropin; a well-known side effect that is usually transient.  There is no mention of a severe allergic reaction, such as hives or swelling.  The medical literature indicates mild stinging and discomfort are not contraindications to Nutropin. There is insufficient evidence in the record of a reaction so severe as to require a change in medication. Further, the medical literature does not support Genotropin as more effective than Nutropin (NuSpin) for this enrollees condition. There is an absence of head-to-head studies in the medical literature demonstrating outcome differences between products.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 pediatrics and pediatric endocrinology 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: The patient has requested authorization and coverage for dexamethasone injections. In this case, the patient has low back pain without radiation into the lower extremities. She has MRI findings of facet arthritis involving L3-4 to L5-S1 without significant spinal canal stenosis. The patients physical examination findings are notable for lumbar paraspinal tenderness and limited range of motion with lumbar extension. The provider has recommended bilateral lumbar medial branch blocks of L3-4 to L5-S1. There is no indication that these injections are for diagnostic purposes to evaluate the patient for a possible radiofrequency ablation procedure. The providers notes suggest that these injections are intended for therapeutic purposes. The randomized control trial by Cohen and colleagues concluded that, facet blocks are not therapeutic. The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. The best evidence for the use of medial branch blocks is for diagnostic purposes leading to a radiofrequency ablation procedure. Therefore, the requested dexamethasone injections are not medically necessary for 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 anesthesiology with subspecialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for radical resection of left retroperitoneal tumor with en bloc left nephrectomy performed in one surgery. Optimal treatment of dedifferentiated liposarcoma requires radical resection. During the initial operation, it is important to attempt to remove all disease while preserving critical neurovascular structures. Researchers found that vascular involvement, positive surgical margins, and histologic grade are the key predictors of disease free survival. For this patient, surgery may include a left nephrectomy. Performance of a radical resection in one procedure with the en bloc left nephrectomy is the standard of care in this clinical setting. Therefore, the requested radical resection of left retroperitoneal tumor with en bloc left nephrectomy performed in one surgery is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested surgery 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 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: The patient has requested authorization and coverage for Caprelsa 300 mg tablets. Desmoid tumors are locally aggressive tumors with no known potential for metastasis or dedifferentiation. However, tumor invasion into vital structures and organs can result in substantial morbidity. Given this patients multiple recurrences, further surgical excision would be difficult. Standard treatment options include cytotoxic chemotherapy, pazopanib, or tamoxifen. There is a lack of peer-reviewed medical literature evaluating EGFR targeting medications in desmoid tumors. Therefore, Caprelsa 300 mg tablets is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested medication is 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:  One reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.