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

Nature of Statutory Criteria/Case Summary: An enrollee has requested orthoptic training for treatment of the enrollees vision problems. Findings: The physician reviewer found that the current medical studies have not demonstrated that vision therapy is more effective than traditional optical or surgical treatment for this patients motility disorders. Scheiman and colleagues noted that patients in all three treatment arms demonstrated statistically significant improvement in symptoms with 42% in office-based vision therapy/orthoptics, 31% in office-based placebo vision therapy/orthoptics, and 20% in home-based pencil pushups. This patient has not reportedly received conventional therapies for his diagnoses including heterophoria, alternating esotropia, hypertropia, diplopia, and accommodative spasm. For these reasons, the requested orthoptic training is not medically necessary for treatment of this 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 ophthalmology 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 coverage for hydroxyprogesterone 1 mg weekly injections for treatment of the enrollees pregnancy. Findings: The reviewer found that the weekly intramuscular progesterone has been shown to be effective in decreasing the risk of preterm birth in women who have a history of prior spontaneous preterm birth. This patient has not had a prior preterm birth. Although she had an episode of preterm contractions, progesterone has not been shown to be effective in significantly delaying delivery in patients with preterm labor that has been effectively treated with other medications. Accordingly, the requested hydroxyprogesterone 1 mg weekly injections are not supported as medically necessary for treatment of this patients medical condition.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 obstetrics and gynecology with sub-specialty certification in maternal and fetal 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 pain medication, Norco for treatment of the enrollee who has a history of pelvic pain, severe cervical dysplasia, and dysfunctional uterine bleeding. Findings: The reviewer found that the submitted documentation fails to demonstrate the medical necessity for the requested medication in this clinical setting. In a study the authors noted that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain. In a study, the author noted that opioid doses should be titrated according to agent-specific schedules to maximize pain relief and maintain tolerability. Tolerance to the analgesic and adverse effects as well as physical dependence, which causes withdrawal symptoms upon discontinuance, may occur with opioid use. Estimates of addiction rates among patients with chronic non-cancer pain range from 3.2 to 18.9%. The provider noted that opioid therapy was not appropriate for this patient. Instead, gabapentin and Cymbalta were recommended as well as acupuncture. There is no documentation that the patient has tried these alternative therapies with the exception of the one week trial of Cymbalta. Therefore, the requested pain medication, Norco is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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 discogram for evaluation of the enrollee who has a history of degenerative disc disease of the cervical spine and low back pain. Findings: The reviewer found that there is a lack of support in the medical literature for the requested procedure in this clinical setting. This patient has multiple non-localizing and non-specific symptoms. The patients neurological examination and electromyogram/nerve conduction velocity were normal. The cervical and brain MRI and computed tomography (CT) scans, after carotid surgery, were also normal. As such, there is a lack of correlation between her studies and with her symptoms except for the myelomalacia and bright cord signal at C5-6, the level of her ADR. Typical post of fibrosis has some tethering effect on the cord and is exacerbated by flexion/rotation of the neck, as she has experienced. In addition, the American Pain Society has noted that the evidence for cervical discography is limited. The American Association of Neurologic Surgeons also has noted that discography is not recommended to formulate treatment strategies for patients with pain. All told, the requested procedure is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested procedure is 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 neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested laminoforaminoplasty with discectomy at C5-6, C6-7 (two-level Deuk Laser Disc Repair) for treatment of the enrollees neck pain with radiation.  Findings: Three physician reviewers found that the Peer-reviewed literature has found that endoscopic discectomy surgery is as effective as traditional discectomy in small volume studies. However, evidence based medical guidelines do not recommend endoscopic discectomy surgery for use in this clinical setting. Overall, peer-reviewed medical literature cites a lack of comparative studies and randomized controlled trials for this type of procedure in the cervical spine to support safety and efficacy. A study conducted a meta-analysis of 24 months of clinical results, and reported that the full endoscopic procedure for discectomy was as effective as traditional discectomy but cautioned that large-volume, well-designed randomized controlled trials with extensive follow-up are needed to confirm and update the findings of this analysis. This patient presents with persistent and worsening cervical radicular pain, limiting his ability to perform activities of daily living. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Providers have recommended anterior cervical discectomy and fusion at the C5-6 and C6-7 levels for imaging findings of spinal canal and bilateral neuroforaminal stenosis. Given the lack of large volume, long-term peer-reviewed outcome studies to support the use of this procedure for this patient, the requested laminoforaminoplasty with discectomy at C5-6 and C6-7 (two-level Deuk Laser Disc Repair) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: 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: All three physician reviewers are board certified in orthopedic 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested spinal muscular atrophy testing for evaluation of the enrollees pregnancy with a family history of Down syndrome.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the spinal muscular atrophy testing performed. Although spinal muscular atrophy may be as frequent as 1 in 40 in the population, the American College of Obstetricians and Gynecologists (ACOG) do not recommend screening at this time. According to the ACOG Committee Opinion for spinal muscular atrophy, Before panethnic prenatal screening for [spinal muscular atrophy] SMA can be recommended there should be a variety of issues addressed which include, but may not be limited to, critical assessment of pilot screening programs, cost effectiveness analysis, development of appropriate educational materials for both patients and primary obstetriciangynecologists, and the development of laboratory assay standards and result reporting. In this case, given that the patient has no known risk factors for spinal muscular atrophy, the testing at issue was not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the testing at issue was 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 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 gene testing PCA3 for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings: Three physician reviewers found that the gene testing PCA3 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. While the dilemma of a biopsy decision in the face of a PSA between 4-10 without overarching clinical concern on physical examination should not be underestimated, there is a lack of medical literature to support PCA3 in the guidance of biopsy decisions over standard laboratory testing. Multiparametric magnetic resonance imaging provides high diagnostic accuracy in identifying patients with prostate cancer in the repeat biopsy setting compared with PCA3 and [prostate health index] PHI. Given the lack of support in the peer-reviewed literature, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the testing at issue was 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: All three physician reviewers 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication H.P. Acthar gel for treatment of the enrollees systemic lupus and ankylosing spondylitis.  Findings: The physician reviewer found that a recent study evaluated H.P. Acthar gel in patients already on other immunosuppressive agents. The authors found that this study suggests a role for Acthar gel as an alternative to corticosteroids in the treatment of systemic lupus erythematosus. Acthar gel appears to be safe and well-tolerated after six months of treatment, with a significant reduction in disease activity (Li, et al). However, this study was a small case series with nine female patients who were on other immunosuppressive agents in addition to Acthar. Another study of 44 patients with systemic lupus erythematosus and nephrotic syndrome (NS) who failed to responds to standard therapy had a response with Acthar. The authors reported that Acthar gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease (Madan, et al). In this case, the records demonstrate that the patient is responding to corticosteroids. There is no history of nephritis and there is a lack of guidelines or large randomized control studies demonstrating benefit of Acthar gel in patients with systemic lupus erythematosus. As such, the request for H.P. Acthar is not medically necessary for treatment of this patients medical condition.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 rheumatology 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 proton beam radiation therapy for treatment of the enrollees prostate cancer.  Findings: Three reviewers found that based upon a review of the medical literature, proton beam radiation therapy is equivalent, but not more beneficial than standard available therapy, photon-based intensity-modulated radiation therapy (IMRT). The theoretical advantage of proton therapy is that it has a Bragg peak, resulting in decreased dose before and after the peak. This translates into a decrease in exposure of normal tissue in the low- to intermediate-dose range, but not in the high-dose range. Dosimetric studies have shown a benefit in bladder and rectal exposure with this regard, but so far, this does not appear to translate into actual decreased clinical side effect (Trofimov, et al; Sheets, et al). In addition, cancer control rates are also reportedly similar between photons and protons (Coen, et al). Accordingly, proton beam radiation therapy has not been established as likely to be more beneficial for treatment of the patients prostate cancer than any available standard therapy.Final Result: All 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: All three physician reviewers are board certified in radiation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  Findings: Three reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breast tissue was described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, bilateral breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.Final Result: Three reviewers determined that the service at issue is 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: All three physician reviewers are board certified in diagnostic radiology and are 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 high intensity focused ultrasound for ablation of prostate tissue for treatment of the enrollees prostate cancer. Findings: Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  Both high intensity focused ultrasound and focal therapy have been increasingly used for treatment of localized prostate cancer within the last decade.  These treatments have the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity.  The available literature mainly consists of prospective case series and retrospective studies showing short-term outcomes for localized prostate cancer.  There is a lack of controlled trials available for analysis, and a lack of long-term survival data is available.  There are no validated biochemical and surrogate end-points for cure.  Therefore, high intensity focused ultrasound for ablation of prostate tissue is not likely to be superior over other treatment options.Final Result: Three reviewers determined that the services at issue 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: All three physician reviewers are 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings: Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Given the support cited above, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue is 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: All three physician reviewers are board certified in diagnostic radiology 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 magnetic resonance imaging (MRI) of the lumbar spine for evaluation of the enrollees low back pain.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records indicate the patients lower extremity examination was normal, with normal reflexes and no weakness or other red flag to indicate an immediate evaluation of the lumbar spine with MRI.  Also, there has been no history of trauma.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested MRI of the lumbar spine is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are 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.