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 proton beam radiation therapy. There is a lack of high quality clinical outcomes or expert consensus national guidelines supporting the use of the proton beam radiation therapy for management of this patients stage IV kidney cancer. The records did not indicate oligometastatic disease. In this clinical setting, dose escalated radiotherapy is not proven to yield superior survival outcomes. Additionally, the submitted proton/photon plan comparison showed that the photon-based treatment plan could have been delivered with an acceptable rate of safety and efficacy, even if dose escalation were required. The records did not show any extenuating circumstances supporting the service at issue, such as prior receipt of external beam radiation to an overlapping field or the presence of a comorbid or genetic condition placing the patient at increased risk for normal tissue toxicity. Therefore, proton beam radiation therapy was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found that proton beam radiation therapy was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.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: Physician reviewers 1, 2, and 3 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that An enrollees parent has requested reimbursement for wilderness therapy services. The records provided for review document that this patient with depressive disorder, generalized anxiety disorder, attention-deficit/hyperactivity disorder (ADHD), combined presentation, developmental coordination disorder, specific learning disorders was admitted to wilderness therapy. A review of the current peer-reviewed medical literature suggests that wilderness therapy may be an effective treatment option for a wide variety of adolescents, including youth with substance abuse problemsand adolescents suffering from depression and various other clinical disorders (Levesque, et al.). Another study compared the effectiveness of three post-acute adolescent substance use situations: outdoor behavioral health (OBH) program, treatment as usual, and no structured treatment. The authors found that in the OBH group, completion rates and treatment outcomes were higher as measured by the Youth Outcome Questionnaire. However, there is a lack of data to support OBH as more effective than other therapies. Although some studies that suggest that patients show some improvement on behavioral health outcomes, there are considerable limitations in the research methodology used to examine these programs and the results remain inconclusive as compared to standard available treatment approaches. Based on the current medical literature, the wilderness therapy services were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the wilderness therapy services were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) of the sinuses and/or CT of the chest. The records provided for review document that this patient presented with four weeks of symptoms including chest congestion, cough, frontal and temporal headache, nasal congestion, sore throat and upper back pain. The patients headaches were noted as sinus and located in both sides of her temples. Treatment has included acetaminophen, as well as Treatment with Vantin and Sudafed, which have provided some improvement in symptoms. The records mention a previous hospitalization for migraine. The visit was telemedicine with no physical examination. The provider has recommended CT imaging of the sinuses and chest. Applying the American Academy of Otolaryngology guidelines, CT of the sinuses is supported for persistent symptoms after four weeks of medical therapy consisting of antibiotics or steroids, to evaluate for potential neoplasm, or when there is clinical suspicion of complication. This patients records do not include documentation of physical examination of the nose or chest to support an indication for CT imaging. In addition, the provider did not chart that the patient has undergone treatment for four weeks or longer for this condition. For these reasons, the requested CT scan of the sinuses and CT scan of the chest are not medically necessary for evaluation 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 otolaryngology with subspecialty certification in neurotology 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 weekly Benlysta 200 mg injections. Findings:  The physician reviewer found that submitted documentation supports the medical necessity of the requested medication. A SELENA-SLEDAI (systemic lupus erythematosus disease activity index) score of 13 is noted in the medical records. She has failed to respond to other standard drugs for SLE treatment, such as hydroxychloroquine. Furie and colleagues performed a phase III, multicenter, randomized, placebo-controlled trial of antinuclear antibody-positive or anti-double-stranded DNA-positive SLE patients with SELENA-SLEDAI scores greater than or equal to 6. This trial included a large number of patients with musculoskeletal symptoms due to SLE, as experienced by this patient. The authors noted that Benlysta was efficacious in controlling SLE symptoms as indicated by statistically significant improvements in SLE responder index scores compared to placebo by 76 weeks. Navarra and colleagues performed a randomized placebo controlled trial that evaluated the safety and efficacy of Benlysta in patients with SLE. A majority of study participants had musculoskeletal disease, as in this patients case. Benlysta use was found to be associated with improved SLE symptoms when compared to placebo by 52 weeks. Therefore, weekly Benlysta 200 mg injections are medically necessary for the treatment of this patient.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ubrelvy 100 mg. The current medical evidence supports the requested medication in this clinical setting. Ubrelvy (ubrogepant) is an oral calcitonin gene-related peptide (CGRP) inhibitor that has been approved by the U.S. Food and Drug Administration (FDA). Ubrelvy is indicated for the acute treatment of migraine with or without aura in adults. Dodick and colleagues performed a randomized trial evaluating the efficacy, safety and side effect profile of Ubrelvy. The authors noted, A higher percentage of participants who received ubrogepant than of those who received placebo had freedom from pain and absence of the most bothersome symptom at two hours after the dose. Although the American Headache Society guidelines have not been updated recently to include oral CGRP receptor antagonists, an addendum article by Pringsheim and colleagues recommended, When an initial treatment (for an acute migraine) does not provide meaningful and sustained benefits, a treatment from a different medication class is typically chosen. In this case, the patient has a history of migraines that have not responded to multiple oral abortive medications. Ubrelvy is an alternative treatment and a different medication class approved by the FDA for the treatment of acute migraines in adults. Therefore, Ubrelvy 100 mg is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for phentermine HCL (37.5 mg tablets, taken once daily). Obesity can lead to numerous complications including type 2 diabetes, hypertension, and cardiovascular disease (Gadde, et al.). This patients records document the presence of obesity as well as multiple comorbidities including type 2 diabetes, hypertension, and dyslipidemia. Son and Kim noted that, As it is difficult to achieve and sustain successful long-term weight loss in most patients with obesity through lifestyle modifications (e.g., diet, exercise, and behavioral therapy), pharmacological approaches to the treatment of obesity should be considered as an adjunct therapy. The U.S. Food and Drug Administration (FDA) has approved phentermine for weight management as an adjunct to caloric restriction and lifestyle modifications for obese and overweight patients with weight-related comorbidities (Narayanaswami and Dwoskin). This patient has reportedly responded well to treatment with phentermine in the past. Given these findings, the requested phentermine HCL (37.5 mg tablets, taken once daily) is medically necessary for treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Adderall XR 15 mg and/or Xanax 0.5 mg #15. The records provided for review document that this patient has diagnoses of autism, GAD, and ADHD. The patient has reportedly benefited from treatment with Adderall XR for ADHD and infrequent use of Xanax for breakthrough anxiety symptoms. On review of the peer-reviewed medical literature, this patients request for continued treatment with Adderall XR and Xanax is supported as medically necessary. As noted by Geffen and Forster, Adult ADHD responds well to integrated pharmacological and psychotherapeutic intervention. Given this patients compliant use of Adderall XR and Xanax, as well as documented benefit in ADHD symptoms from the medication regimen, continued treatment with Adderall XR is appropriate (Hoge, et al.). Moreover, the patient only requires treatment with Xanax infrequently as a rescue medication in addition to a selective serotonin reuptake inhibitor (SSRI) for management of the patient's panic symptoms. For these reasons, Adderall XR 15 mg and Xanax 0.5 mg #15 are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy (PBRT). The records provided for review document that this patient has a history of metastatic esophageal cancer with small pulmonary nodules and lesions in his spine and liver after treatment with chemotherapy. The patients provider has recommended palliative proton beam radiotherapy due to the presence of metastatic disease. As noted in the medical literature, during palliative radiotherapy for esophageal cancer or bone metastases, the standard of care includes treatment with photons. There is a lack of clinical data to suggest that proton beam radiotherapy is associated with improved outcomes or decreased toxicities compared to treatment with photons. In this clinical setting, treatment to the spine and esophagus at palliative doses are associated with low rates of toxicities. The plan comparison between this patients photon plan and the proton plan does not provide sufficient justification for the use of proton therapy. Cardiac toxicities are typically not a major complication in patients undergoing palliative radiotherapy, and the decreased doses observed in the proton plan were not likely to be associated with any clinical benefit for this patient. All told, the PBRT was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the PBRT was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for arthroscopy shoulder biceps tenodesis (CPT 29828) and open repair of rotator cuff chronic (CPT 23412) (along with approved procedures CPT codes 29826, 29827, 29823, and 23430). Findings:  The physician reviewer found that McElvany and colleagues concluded that there is a paucity of evidence that the results of rotator cuff repair surgeries provide improved health outcomes in published studies between 1980 and 2012. The authors noted that, While the number of relevant articles published per year increased dramatically over the period of the study, the clinical and anatomic results did not show improvement over this period. Hawi and colleagues concluded that in cases of unsuccessful conservative treatment and correct indications, a high level of patient satisfaction can be surgically achieved. This patient is being treated for post-traumatic left shoulder partial subscapularis tear with long head biceps subluxation/dislocation. He presented on 11/16/21 being is approximately six weeks after a motorcycle versus auto accident. The patient reports left upper arm pain and symptoms. Physical examination of the left shoulder revealed localized tenderness about the greater tuberosity, subacromial bursa and anterior bicipital groove. The patient has been approved for CPT 29826 shoulder arthroscopy, subacromial decompression, CPT 29827 arthroscopy with rotator cuff repair, 29823 shoulder arthroscopy debridement extensive, and 23430 tenodesis of long tendon of biceps. However, detailed documentation is not evident regarding the need for the surgical procedure to be performed both arthroscopically as well as open. For these reasons, the requested arthroscopy shoulder biceps tenodesis (CPT 29828) and open repair of rotator cuff chronic (CPT 23412) (along with approved procedures CPT codes 29826, 29827, 29823, and 23430) 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tadalafil 20 mg twice daily. Findings:  The physician reviewer found that On review of the medical records and current peer-reviewed medical literature, the requested tadalafil 20 mg twice daily is likely to be more beneficial for treatment of this patients Raynauds than any other available standard treatment. There is documentation that this patient has severe Raynauds due to systemic sclerosis with fingertip pain, digital ulcers, and dusky pale appearing fingers with areas of ischemia noted on the digits. The patient has failed to respond to or has been unable to tolerate other standard treatments for severe Raynauds such as calcium channel blockers, sildenafil, and epoprostenol. The patient is being treated with tadalafil 20 mg twice daily with good results for her severe Raynauds. Although there are limited data available, review of the medical literature does support the use of tadalafil for the treatment of patients with Raynauds in this patients clinical setting. Roustit and colleagues performed a meta-analysis of six randomized controlled clinical trials on the use of a phosphodiesterase type 5 (PDE-5) inhibitor in the treatment of patients with Raynauds. The authors concluded that the use of a PDE-5, such as tadalafil, significantly reduced the mean Raynauds condition score as well as the frequency and duration of ischemic attacks. For these reasons, the requested tadalafil 20 mg twice daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested tadalafil 20 mg twice daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is 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 1 is board certified in internal medicine with subspecialty certification in rheumatology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in rheumatology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in rheumatology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. There is a lack of support for the requested services in this clinical setting. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Researchers  performed a recent multi-institutional analysis of 1,850 patients with low-risk or intermediate-risk prostate cancer. The authors compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, the authors found no difference in disease control between the two modalities. The American Society of Radiation Oncology (ASTRO) noted, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton beam radiation therapy has been demonstrated over standard treatment with photons and intensity-modulated radiation therapy technique. Therefore, the requested proton beam radiation therapy is 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.