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 breast magnetic resonance imaging (MRI) provided for evaluation of the enrollee, who had an abnormality on a mammogram. Findings:  The 3 physician reviewers found that there is sufficient support for the services at issue in this clinical setting. In this case, mammograms clearly showed a new area of abnormality. However, the problem was that it was only visualized on one view, and could not be localized on the second view.  The sonogram that was performed did not help resolve the issue.  This patients mammographic findings necessitated further work-up.  Breast MRI was needed for localization and/or confirmation.  Thus, breast MRI provided was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 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 number one 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.Physician reviewer number two 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.Physician reviewer number three 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco for treatment of the enrollees chronic pain. Findings: The physician reviewer found that opioid medication can be considered as part of the standard of care when treating patients with chronic nonmalignant pain. Concern for opioid misuse can result in under treatment of pain and opioids are frequently used because there are few alternative agents that offer the same level of analgesia. These factors can make it challenging for providers to balance pain relief with the risk of creating or fueling addictive behavior. Alternative therapies such as acupuncture, yoga, meditation, chiropractic care, massage, and cognitive behavioral therapy are not considered a replacement for analgesic medications. Controlled trials have shown a modest effect in terms of analgesia with opioids. Many patients currently receiving long-term opioids were started when opioids were still considered a viable treatment option and, if these patients are satisfied with their pain control and using their medications appropriately, they should not be unilaterally compelled to wean from opioid use. Judicious prescribing and monitoring remains a viable option for select patients. In this case, the patient had been taking Norco on a long-term basis. There were no issues of abuse or addiction. The patient is expected to have some predictable activity-related breakthrough pain, consistent with her history of foot injury. For these reasons, Norco has been established as medically necessary for 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 physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX device for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that The records demonstrate that this patient has GERD as based on pH recording. However, the patient has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs. Also, implantation of LINX in this patients setting must be approached with caution given his altered distal esophageal anatomy following the TIF surgery, and uncertain status of his upper gastrointestinal motility. Based on these findings, the requested LINX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested procedure 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 reviewer number one is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or 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 transcranial magnetic stimulation (TMS) for treatment of the enrollees major depressive disorder.Findings:  The physician reviewer found that the documentation submitted for review indicates the patient has a history of an inpatient admission in April 2015 with a primary diagnosis of bipolar disorder, most recent episode depressed, severe without psychotic features and an intensive outpatient program admission in May 2015 with a primary diagnosis of unspecified bipolar disorder. The record indicates that the patient has been treated with Geodon which is not a typical augmentation therapy or monotherapy agent for major depressive disorder. Given that the records support a history of bipolar disorder and lack of peer-reviewed literature supporting TMS for patients with bipolar disorder, the request for TMS treatment is not indicated. In addition, the patient had a Montgomery-Asberg Depression Rating Scale (MADRS) score of 42 indicating severe depression. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 55-year-old female enrollee has requested authorization and coverage for methadone 10 mg, Vicodin 10 mg, Norco 325 mg, and hydrocodone for treatment of the enrollees degenerative disc disease, bilateral knee joint pain, and lumbar facet arthropathy. Fulfills Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative settings. The Centers for Disease Control and Prevention (CDC) also state when opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, carefully reassess evidence of individual benefits and risks when considering increasing dosage of 50 or more morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or more MME per day. In this case, the patient was recently taking well over 90 MME per day. However, in the documentation provided for review, no objective treatment goals for pain and function are noted for the requested medication and several requirements for opioid prescribing have not been documented. Further, dose escalation is a short-term, not long-term plan. Increases in the past appear to have been done only on the basis of the patients pain levels and not all other non-pharmacological methods such as behavior therapy of treating the patients pain have been addressed. Finally, the current taper plan is reasonable and there is a lack of documentation supporting these medications to alter the current taper plan. For these reasons, the request for authorization and coverage for methadone 10 mg, Vicodin 10 mg, Norco 325 mg, and hydrocodone, are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medications 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 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: A 40-year-old male enrollee has requested authorization and coverage for Otezla 30 mg for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that this patient presents with a history of plaque psoriasis affecting the scalp, face and body. He has failed therapy with topical steroids and topical vitamin D analogues. The patient has not tried and failed treatment with methotrexate, cyclosporine, or the preferred injectable biologic agents. As there is no documentation of contraindications or side effects from the use of these medications, the requested Otezla is not supported as medically necessary as the Health Plans formulary options are likely to be as or more beneficial in the treatment of the patients plaque psoriasis. Thus, the requested Otezla 30 mg is not medically necessary for treatment of this patients plaque psoriasis. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for hormone pellets on for the treatment of the enrollee who has a history of low testosterone and low estrogen levels. Findings:  Three physician reviewers found that compounded drugs are not regulated by the U.S. Food and Drug Administration (FDA). They have the same risks as FDA approved hormone therapies, and they also may have additional risks because of the way they are made. There is a lack of scientific evidence that compounded hormones are safer or more effective than standard hormone therapy. Because of a lack of FDA oversight, most compounded preparations have not undergone any rigorous clinical testing for either safety or efficacy, and the purity, potency, and quality of compounded preparations are a concern. Some of these more traditional therapies may include, exercise weight loss, topical lubricants and moisturizers, topical estrogens, stress reduction, biofeedback, counseling, and serotonin reuptake drugs. In this patients case the chart indicates a list of the patients menopause complaints, but there is no mention of management options. The records provided do not indicate whether the patient has tried any other medicinal and nonmedicinal form of therapy. Despite the success this patient may be experiencing with her menopausal symptoms with her current therapy, the medical evidence does not support its superiority as first line therapy. Final Result: Three reviewers determined that the medication at issue was not and 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: All three physician reviewers are board certified in obstetrics and gynecology 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: A  female enrollee has requested authorization and coverage for Myobloc (Botox) injections for treatment of the enrollee who has a history of fibromyalgia, irritable bowel syndrome, piriformis syndrome, and ankylosing spondylitis. Findings:  The physician reviewer found that The documentation provided notes that the requested treatment option was to address the patients piriformis syndrome, a variant of myofascial pain syndrome. A small study by Fishman and colleagues compared Botox injections with corticosteroid and lidocaine injections for the treatment of piriformis syndrome and found a greater decrease in pain with Botox injections.  An open label comparator study by Yoon and colleagues noted that Botox appeared superior to dexamethasone with lidocaine by the visual analogue scale. Although the evidence supporting Botox in this clinical setting appears less robust than what may be desired, Myobloc (Botox) injections into the piriformis muscle appears to be superior to the conventional therapy with corticosteroids and lidocaine for the treatment of this patients medical condition. Final Result: Two of three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the psychiatric residential treatment center (RTC) for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). The patient was at significant risk of harm (score 3) with a history of suicide attempts and self-injurious behavior. The patient did not have any active suicidal or homicidal ideation. The patient demonstrated moderate functional impairment (score 3) since her substance use has impaired her ability to perform adequately in school. The patient has a co-morbidity of polysubstance use and depression (score 3). The patient has a moderately stressful recovery environment (score 3) that is supportive (score 2). The patients response to treatment has been equivocal (score 3) with prior outpatient treatment and inpatient treatment. She is at times obstructive with care and at other times will passively accept care. She has demonstrated an inconsistent capacity to deal with stressors and has demonstrated a limited ability to follow-up with treatment recommendations. Overall, the patient has been obstructive to treatment (score 3) and demonstrated distrustful relationships with providers. The patient acknowledged the existence of a problem but resisted accepting responsibility for perpetuation of the problem. She will frequently rationalize behaviors and consequences. She has a history of being noncompliant with treatment. This gives the patient a composite score of 20, which meets the criteria for a partial hospitalization program (PHP). The records indicate that although the patient continued to need treatment for her substance use and depression, she had progressed enough to be treated at a less restrictive environment. Therefore, the RTC 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 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 child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the Bioness L300 for treatment of the enrollee, who is status post arteriovenous malformation rupture. Findings:  The physician reviewer found that although a functional electrical stimulation is not indicated for all patients with hemorrhagic strokes and hemiparesis, there is medical literature supporting its use for a select population of patients. The literature has demonstrated the safety and efficacy of this device for patients with chronic upper motor neuron disease such as what occurs in foot drop induced by stroke. This patient has documented lower leg weakness secondary to the rupture of the arteriovenous malformation. In the past, she had a suboptimal response to an ankle foot orthosis.  Given that this patient had a suboptimal response to standard therapy, the Bioness L300 was likely to have been superior over other available treatment alternatives. Final Result: Two of the three reviewers determined that the device at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified 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.Physician reviewer number two is board certified 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.Physician reviewer number three is board certified 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: A male enrollee has requested reimbursement for the Monovisc injection for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient is being treated for near end stage osteoarthritis of the knee. The quality of data to support the efficacy of viscosupplementation for the treatment of knee osteoarthritis is questionable. Multiple large specialty governing bodies do not recommend viscosupplementation given the lack of consensus high-quality evidence.  Specifically in this case, there has been a pattern of decreased duration of symptomatic relief of less than six months.  Thus, an additional series of viscosupplementation was not supported. All told, the Monovisc injection was not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.