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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the occipital nerve block for treatment of the enrollees occipital neuralgia, neck pain, and muscle spasm of cervical muscle of neck.  Findings:  Two physician reviewers found that the records indicate the presence of occipital neuralgia as documented by physical examination findings. Occipital nerve blocks are supported for diagnostic purposes but are not supported for therapeutic treatment as there is a lack of long-term benefit supported by the peer-reviewed medical literature. Researchers reported that there was no long-term improvement of headache of chronic migraine type with use of occipital nerve block. Other researchers found that greater occipital nerve blocks do not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Other researchers noted there was no long-term improvement of chronic migraine with use of occipital nerve blocks. Final Result: The reviewers determined that the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1 is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. Reviewers 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dextroamphetamine tablet for treatment of the enrollees demyelinating disease of central nervous system. Findings:  The physician reviewer found that Adderall is not U.S. Food and Drug Administration (FDA) approved for fatigue management related to multiple sclerosis. In the medical literature, it is noted that multiple therapeutic treatments are available for multiple sclerosis related fatigue. However, the authors noted that Adderall is not supported in the peer-reviewed medical literature for use in this clinical setting. Further, it is reported that Adderall has not shown benefit in treatment of patients with fatigue related to multiple sclerosis. 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: The patient has requested reimbursement and prospective authorization and coverage for dual diagnosis residential treatment services provided. Findings:  The physician reviewer found that the patient was not at imminent risk for severe withdrawals and his post-acute withdrawal symptoms were mild. He was not a danger to himself or others, and he did not demonstrate self-harm urges or behaviors. There were no emotional, behavioral, or cognitive issues warranting residential services. He was not psychotic or delusional. He was not impaired such that he could not perform his activities of daily living. There were no new problems that arose. He was making progress, was motivated, and engaged in his treatment plan. He was medically stable, and his psychiatric medications could have been monitored and adjusted on an ambulatory basis in the outpatient treatment setting. In addition, the patient had not attempted treatment at a lower level of care prior to residential treatment. Although relapse risk is inherent in patients in the substance abuse population, this is not an adequate to support treatment in the residential setting. The patients emotional issues addressed in psychotherapy could be continued on an ambulatory basis, as could his substance abuse treatment in conjunction with community support services such as a 12 step program and counseling. The patient no longer required residential level of care. Accordingly, the dual diagnosis residential treatment services provided were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty certification 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for neratinib (Nerlynx). Findings:  The physician reviewer found that currently, Nerlynx is indicated for the extended adjuvant treatment of early stage HER2-positive breast cancer, after completion of adjuvant trastuzumab based therapy. Per the U.S. Food and Drug Administration (FDA) approval, Nerlynx is also used for extended adjuvant therapy after Herceptin based therapy in early breast cancer. However, Nerlynx is not approved for metastatic disease. Moreover, there is a lack of peer-reviewed medical literature reporting improved health outcomes in patients with use of Nerlynx in this clinical setting. For these reasons, the requested Nerlynx 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: Physician reviewers 1,2 & 3 are  certified in internal medicine with sub-specialty 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that residential treatment center services provided were not medically necessary for treatment of the patients behavioral health condition. According to the documentation submitted for review, the patients post-acute withdrawal symptoms were not severe in nature. The patient was not a danger to self or others, nor aggressive or violent. The patient was cognitively intact and not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that support the level of care provided. The patient was medically and psychiatrically stable. The patients medication management could have been performed in an ambulatory setting. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with the patients care. The patient was motivated and appeared to be working the program. The patient was cooperative and participating in his treatment plan. Although the patient continued to struggle with emotions and required further treatment to help develop coping skills, this did not require the structured environment of a residential setting and could have been provided in an ambulatory level of care. The patient lived with family in a safe, supportive environment. The patient no longer met American Society of Addiction Medicine clinical guidelines for residential level of care. As such, the residential treatment center services were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of your medical condition. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar microdiscectomy for treatment of the enrollees low back pain. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. This patient presents with persistent low back pain radiating into the left lower extremity to the calf, with numbness and tingling localized to the plantar foot. His symptoms were aggravated by sitting, standing, walking, and bending. His symptoms interfered with activities of daily living. Clinical examination findings evidenced sensory deficits and reflex changes consistent with imaging evidence of L3-L4 and L4-L5 disc protrusions with nerve root compromise. Selective nerve root blocks at left L4 and L5 provided temporary symptom relief. He had failed to improve despite long-term non-operative treatment, including medications, physical therapy, chiropractic care, activity modification, and injections. The medical evidence supports the requested services in this clinical setting. Final Result: The reviewer determined that the requested services 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for H.P. Acthar gel 80 units for treatment of the enrollees lupus nephritis. Findings:  The physician reviewer found that the records indicate that this patient has been treated with first-line standard of care and has failed to experience an adequate response. The morbidity implications of persistent refractory proteinuria are significant. Acthar gel is U.S. Food and Drug Administration (FDA) indicated for nephrotic range proteinuria and has been used successfully to treat lupus nephritis. In the peer-reviewed medical literature, Researchers concluded that in patients with systematic lupus erythematosus, Acthar gel may provide significant disease activity reduction. Given this support, the requested H.P. Acthar gel 80 units is medically necessary for treatment of this patients persistent nephrotic range proteinuria. 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 nephrology 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 perinatology follow-up visit, ultrasound, and Doppler velocimetry testing for the evaluation and treatment of the enrollees pregnancy.  Findings:  The physician reviewer found that the general recommendations for ultrasound in pregnancy include a dating ultrasound in the first trimester and/or an ultrasound for nuchal translucency if the patient requests genetic testing. In the second trimester, all patients should receive an anatomy scan.  Follow-up ultrasounds in addition to those are recommended based on maternal medical history or abnormal fetal findings. In this case, the records support the requested ultrasound. However, the records do not document an indication for Doppler velocimetry testing in this case, such as fetal anemia or growth restriction. Additionally, the requested perinatology follow-up is not indicated at this time. A perinatology follow-up may be needed if there were a new high-risk abnormality found. In sum, the requested ultrasound is medically necessary for the evaluation and treatment of this patient. However, the submitted records fail to demonstrate the medical necessity of the requested perinatology follow-up visit or Doppler velocimetry testing. Final Result: The reviewer determined that a portion of the requested services is medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for durable medical equipment, RT300 functional electrical stimulation (FES) cycle therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that yhe patient is approximately one year status post traumatic spinal cord injury as described above. In terms of recovery after spinal cord injury, most recovery occurs in the first six to 12 months. However, recovery can extend beyond one year, and neurologic recovery continues for perhaps up to two years. In this patients case, further neurological recovery may occur. The patient has an incomplete, mid-level cervical spinal cord injury. The patient has ongoing spasticity. There are no reported episodes of autonomic dysreflexia or active skin issues. However, use of the RT300 FES cycle therapy would carry potential risks of pressure ulcer formation, autonomic dysreflexia, post exercise hypotension, thermal dysregulation, as well as other musculoskeletal injuries.  In terms of functional abilities and at the patients neurological level of injury, the patient would be expected to be able to use conventional equipment for strengthening and an upper extremity or wheelchair ergometer for cardiovascular exercise. The patient is already using a standing frame and may progress to ambulating with bracing, likely on a limited basis for exercise. While this system may have benefits as a preventative measure and as a means of exercise, the RT300 FES Cycle Therapy would not treat the patients spinal cord injury. Although exercise is beneficial and highly recommended, the RT300 FES cycle therapy was not likely to have been more beneficial than the standard options available for treatment of this patients medical condition. Final Result: The reviewers determined that the equipment at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet rich plasma (PRP) injection. Findings:  The physician reviewer found that current evidence based medical guidelines recommend a single platelet rich plasma (PRP) injection as a second line therapy for chronic lateral epicondylitis after first line treatment of physical therapy such as eccentric loading, stretching and strengthening exercises. Peer reviewed literature supports the use of PRP in recalcitrant lateral epicondylitis as providing clinically significant pain reduction and functional improvement. However, in this patients case, there is a lack of evidence to indicate that he has fully optimized conservative treatment. This patient presented with a six month history of right elbow pain. Symptoms were worse with playing golf. Clinical examination findings were consistent with the diagnosis of right lateral epicondylitis. The patient has tried some anti-inflammatory medications with some benefit. He was not able to avoid the aggravating activity because he is a golf instructor. The provider recommended a trial of elbow strapping, continued anti-inflammatory medications, home exercises, and referred the patient to occupational therapy. A PRP injection was recommended for the right elbow as a first line injection over corticosteroid injection. While there is current evidence based medical guideline and peer reviewed literature to support a single PRP injection in the treatment of recalcitrant lateral epicondylitis, this patient has not exhausted all the available conservative treatment options available. Therefore, the PRP injection is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: Two of the three 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 reviewers 1, 2 & 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are 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 acupuncture services for treatment of the enrollees cough. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The use of acupuncture for the treatment of chronic cough is not supported in the peer-reviewed literature. In addition, the documentation submitted for review does not describe the severity of the patients cough, and/or the level of disability the patient experiences due to her chronic ailment. As such, the request for acupuncture is not supported as 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 oriental 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 magnetic resonance imaging for evaluation of the enrollee, who reported a history of neck pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The American College of Radiology guidelines do not support magnetic resonance imaging in this clinical setting. It is well-known that abnormalities detected on magnetic resonance imaging of the spine do not necessarily correlate with symptoms.  There are innumerable patients who are relatively asymptomatic, but have significant abnormalities on magnetic resonance imaging. The physical examination is generally more important than magnetic resonance imaging findings. Researchers reported the examiner should avoid overreliance on medical technology in making their assessment because this approach is fraught with false-positive and false-negative pitfalls that may be harmful to the patient. The current medical evidence does not support the services at issue in this patient. This patient has a history of neck pain. However, a trial of intensive anti-inflammatory medications as well as physical therapy and other conservative measures is warranted before magnetic resonance imaging is performed. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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.