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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne CDxTM comprehensive genomic profiling test (F1CDx). The records provided for review document that this patient has a history of ovarian cancer status post debulking surgery and multiagent chemotherapy including clinical protocols. Pathology revealed high grade serous carcinoma, involving left ovary and fallopian tube, uterine serosa with focal myometrial invasion, and cervical stroma. Close follow-up has revealed progressive disease. The patients tumor was submitted for analysis with FoundationOne CDxTM comprehensive genomic profiling test (F1CDx). According to the National Comprehensive Cancer Network (NCCN) guidelines and the National Cancer Institute (NCI), it is important to know the presence of germline or somatic mutations in BRCA 1 and/or BRCA2 in order to appropriately treat this patient (Armstrong, et al.). She may be offered certain therapies or treatment in a clinical trial based upon mutational status (Ledermann, et al.; Kaufman, et al.). In light of the current data, the F1CDx was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the F1CDx was 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 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 1 is board certified in internal medicine with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a L4-L5 artificial disc replacement surgical procedure (CPT 22857). The submitted documentation supports the medical necessity of the requested service. The U.S. Food and Drug Administration (FDA) has approved ProDisc-L total disc replacement for spinal arthroplasty in skeletally mature patients with degenerative disc disease (DDD) at one or two consecutive levels from L3 to S1. The FDA further notes that the patient should have no more than grade 1 spondylolisthesis at the involved level(s) and have failed at least six months of conservative treatment. The FDA notes that contraindications include active systemic or site infection, osteopenia or osteoporosis, bony lumbar spinal stenosis, isolated radicular compression syndromes especially due to disc herniation, and pars defect. In a follow-up at the five-year mark of 236 patients who underwent either ProDisc-L total disc replacement (TDR) or fusions, researchers noted that the TDR group had significantly better improvement on some scales, and while TDR patients avoid the stiffness of fusion and are more satisfied than fusion patients, both fusion and TDR were reasonable surgical options in this specific patient population. In this case, the patient is being treated for low back pain. Recent records noted that the patient had developed urinary urgency. She also reported increased pain involving the lower back and legs. There is sufficient support for the requested service in this clinical setting. Therefore, the requested L4-L5 artificial disc replacement surgical procedure (CPT 22857) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility services. There is a paucity of evidence in current medical literature supporting significant rehabilitation interventions, outside of obtaining compensatory skills, following significant lower limb fractures. Researchers reported little evidence for rehabilitation interventions during the immobilization period after conservative orthopedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilization period.  Researchers found that a supervised exercise program and advice did not confer additional benefits in activity limitation or quality of life compared with advice alone for patients with isolated and uncomplicated ankle fracture. The authors further noted that their findings did not support the routine use of supervised exercise programs after removal of immobilization for patients with isolated and uncomplicated ankle fracture. In this case, the patient has undergone rehabilitation but continues to have limited functions due to morbid obesity, marginal functional status at baseline, and weight bearing restrictions on his left leg. He remains dependent for transfers and is non-ambulatory, requiring total assistance for his lower body self-care. Given that the records do not reflect ongoing goals or other medical, nursing, or rehabilitation needs until his weight bearing status is liberalized, the requested services are not medically indicated. Therefore, skilled nursing facility services are 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 physical medicine and rehabilitation 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 patient has requested authorization and coverage for bilateral knee replacement surgeries. Researchers concluded that the risk-to-benefit for total knee arthroplasty favors patients who have intense or severe symptoms of knee osteoarthritis, are at least 55-years-old, have limited mobility, and have a body mass index (BMI) less than 40 kg/m2. The authors concluded that outcomes are substantially less favorable for patients who have slight or moderate symptoms and functional loss. This patient is being treated for bilateral knee osteoarthritis. The patient reports persistent knee pain. X-rays demonstrated osteoarthrosis especially at the medial compartment, mild to moderate, left more than right, with joint space narrowing. However, detailed documentation is not evident regarding updated physical examination findings for the left and right knees. There is a lack of data regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Furthermore, the patient is noted to be obese with a BMI over 45 kg/m2, without evidence of a comprehensive trial and failure of BMI management. Therefore, the requested bilateral knee replacement surgeries 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar fusion of the L4-5 and L5-S1. Findings:  The physician reviewer found that prospective methodology with a broad definition of complications, Campbell and colleagues reported a significantly higher perioperative incidence of complications than previously indicated after spinal fusion procedures. Given the increased application of instrumentation, especially for degenerative disease, the authors noted a better estimate of clinically relevant surgical complications could aid spine surgeons and patients in an individualized complication index to facilitate a more thorough risk-benefit analysis prior to surgery. In an analysis of perioperative morbidity and mortality after anterior, posterior, and anterior/posterior spine fusion surgery, Memtsoudis and colleagues concluded that, despite being performed in generally younger and healthier patients, anterior/posterior spine fusion and primary anterior spine fusion were associated with increased morbidity and mortality. The authors noted that these findings could be used for the purposes of risk stratification, accurate patient consultation, and hypothesis formation for future research. In this case, the patient has chronic lumbar pain with intermittent lumbar radiculopathy and is being treated for multi disc degeneration. He reports persistent pain and is unable to sit for more than ten minutes at a time despite continued conservative care. On examination, he had altered sensation in the anterior shin and the left dorsal foot. Magnetic resonance imaging (MRI) of the lumbar spine revealed disc degeneration at L3-4 and L5-S1 with annular tears L3-4 and L4-5 and dark discs at L3-4-5-1. However, dynamic flexion-extension x-rays and MRI imaging did not show instability and/or a reference to impending intraoperative instability. In this clinical setting, the requested service is not medically indicated. Therefore, lumbar fusion of the L4-5 and L5-S1 is not medically necessary for the treatment of this 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral sacroiliac radiofrequency ablation. King and colleagues report that the literature on sacral lateral branch interventions is sparse. The authors found that one study demonstrated the face validity of multisite, multidepth sacral lateral branch blocks for the treatment of posterior sacroiliac complex pain, and some evidence of moderate quality on therapeutic procedures, but concluded that there was insufficient evidence to determine the indications and effectiveness of sacral lateral branch thermal radiofrequency neurotomy. In this case, the patient has sacroiliac joint dysfunction and sacroiliitis and reported axial low back pain radiating to the buttocks without radicular pain down to his legs. He rated his pain at an eight out of ten and noted that it was alleviated by laying down, sitting and injection therapy. The patient reported that previous bilateral sacroiliac blocks provided 75% to 80% relief, with visual analog scale (VAS) decreasing to three out of ten for six hours following the diagnostic block. Given the limited published peer reviewed literature on the safety and efficacy of the requested service in this clinical setting, the requested service is not medically indicated. Therefore, bilateral sacroiliac radiofrequency ablation is not medically necessary for the treatment of this 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan. This patient presents with metastatic renal cell carcinoma status post right nephrectomy. Recent PET imaging demonstrated interval development of dense consolidation of paramediastinal locations of the apices. The patient has requested further evaluation with PET scan. PET is not indicated for the initial work-up of patients with renal cell carcinoma. However, this patient has advanced disease, and the requested PET scan is not part of the patients primary evaluation. The role of PET in the treatment of renal cell carcinoma can be most effective in the detection of metastatic disease, thus influencing therapeutic decisions (Liu). In addition, PET can be informative for postoperative surveillance and restaging when conventional imaging is inconclusive. Accordingly, the requested PET scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested PET scan is likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in diagnostic radiology and is actively practicing. Physician reviewer 3 is board certified in diagnostic radiology and is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Taltz.Taltz has been approved by the U.S. Food and Drug Administration and is indicated for the treatment of moderate-to-severe psoriasis. Based on the psoriasis treatment guidelines put forth by the American Academy of Dermatology-National Psoriasis Foundation (AAD-NPF), patients who have psoriasis affecting between 3-10% (defined as moderate) and greater than 10% (defined as severe) of their body surface area are candidates for phototherapy and systemic medical therapy. There are no step therapy guidelines recommended in this context, and the choice of therapy should be made at the discretion of the treating provider with attention paid to the patients comorbidities. In this case, the patient has periumbilical psoriasis. This area is difficult to treat with topical medications. In this case, the records document a PASI score of 25, and treatment with Taltz has reportedly been effective. There is sufficient support for the requested medication in this clinical setting. Based on these factors, Taltz is medically necessary for the 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ipratropium bromide solution 0.02%.The requested ipratropium bromide solution 0.02% has been approved by the U.S. Food and Drug Administration and is supported by the medical literature as rescue therapy in COPD. In this case, the patient is a former smoker with COPD, currently managed on Anoro Ellipta, a long-acting beta agonist (LABA) and long-acting muscarinic antagonist (LAMA), and beclomethasone (QVAR), an inhaled corticosteroid (ICS). The patient is also managed with rescue therapy, including a short-acting beta agonist (albuterol), and short-acting muscarinic antagonist via nebulizer (ipratropium bromide solution 0.02%). The patient has been effectively managed with ipratropium bromide solution 0.02% based on an excellent response by clinical history. Thus, the requested ipratropium bromide solution 0.02% is medically necessary for the 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Saxenda.Obesity is associated with increased risk of multiple comorbidities. Few medications are currently available for the treatment of obesity, and their effectiveness and benefits often fade when the drugs are discontinued. Saxenda (liraglutide) may be prescribed for chronic weight management as an adjunct to a reduced-calorie diet and increased physical activity. Researchers noted, Data demonstrated that liraglutide can successfully achieve weight-loss benchmarks of 5% or more and 10% or more loss from baseline. In this case, the patient has struggled to lose weight despite a low calorie diet and regular exercise. Saxenda may assist this patient with losing weight and may have a positive effect in terms of her comorbidities related to her obesity, such as polycystic ovary syndrome. Thus, the Saxenda is medically necessary for the treatment of the patients 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 sub-specialty certification in endocrinology, diabetes and metabolism 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 wipes.Researchers state that risk factors for development of incontinence-associated dermatitis include compromised skin (e.g., due to aging, steroid use or local trauma/friction), immobility, decreased cognitive awareness, inability to perform personal hygiene, pyrexia, and poor nutritional status. Due to a lack of high quality experimental literature, prevention and treatment of incontinence-associated dermatitis is largely guided by expert opinion and focused on addressing the incontinence itself when feasible, timely clean up following incontinent episodes, and applying skin protectants, such as barrier creams. With respect to specific cleansing products and techniques, traditional soap (which has an alkaline pH) and water are generally considered poorly effective in preventing and treating incontinence-associated dermatitis. Researchers state that healthy skin has a pH of approximately 5-5.5 and the use of alkaline products has been observed to promote an environment that favors bacterial growth. Researchers state that experts have recommended the use of bath or shower oils without allergens or pH-neutral cleansing foams applied on soft, single-use cloths for a gentle cleansing of the skin, followed by simple patting with an absorbent towel to avoid the friction damage associated with rubbing. Regular application of a thin layer of a hydrating barrier cream optimized for the individuals skin and circumstances is also recommended as a consideration. In this case, there is no specific need for the Prevail Adult Washcloths in question, which are disposable cloths infused with a blend of lotions containing aloe and vitamins. The item in question is a convenience item used for bodily hygiene that combines disposable wipes with lotions, which are otherwise readily commercially available for routine bodily hygiene. Thus, the requested wipes are not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested supplies 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 physical medicine and rehabilitation 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.