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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for referral to a registered dietician. Findings:  The physician reviewer found that treatment of adult obesity includes education and training regarding a comprehensive lifestyle change with dietary therapy, exercise, behavior modification, and if needed, drug therapy. Identifying an individuals risk for adverse medical outcomes due to obesity is needed to determine the most effective or necessary approach. Individuals with a BMI of 30-34.9 kg/m2 are at moderate risk. These individuals should be offered or referred to intensive, multicomponent behavioral intervention programs that include information that will enable them to make dietary changes and increase physical activity. Medication management should also be considered. The initial step for management and education should reasonably come from a medical provider. The goal of dietary therapy is to reduce the total number of calories consumed. There is no one single diet that fits all individuals. In this case, the submitted documentation does not reflect that the patient has failed an attempt at weight loss with the medical weight management program that is available at the recommendation of her provider. Additionally, there is no indication that the patient has received education from her provider regarding dietary changes or that her medical provider is unable to provide education regarding dietary changes. Under these circumstances, the requested referral to a registered dietician is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal 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 enrollees parent has requested reimbursement for wilderness therapy services. Current medical literature suggests that wilderness therapy may be an effective treatment option for a wide variety of adolescents, including youth with substance abuse problems and adolescents suffering from depression and various other clinical disorders, and improve interpersonal relationships. However, there is a lack of evidence supporting the claim that outdoor behavioral healthcare programs are superior to standard therapies as a treatment intervention for adolescent substance use and mental health disorders. Few studies directly compare outcomes of outdoor behavioral healthcare programs to other therapeutic interventions. Researchers note that in a scoping review of direct comparison trials in adventure therapy, only 13 studies met the full inclusion criteria. The authors found few significant differences to isolate specific therapeutic factors. While literature on outdoor behavioral healthcare programs suggest that participants show some level of improvement on behavioral health outcomes, the results are not conclusive. There is a lack of randomized controlled trials or well-designed cohort studies that would allow for causal conclusions about the impact of outdoor behavioral healthcare programs. In this clinical setting, there is a lack of data to support the claim that outdoor behavioral healthcare programs were more effective than other therapies. Therefore, wilderness therapy services were not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been 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 and 3 are board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and are actively practicing. Physician reviewer 2 is board certified in psychiatry and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for custom molded foot orthotics. Findings:  The physician reviewer found that the enclosed information, the requested custom molded foot orthotics are supported as medically necessary for treatment of this patient. The medical documentation reports that this patient is being treated for painful left plantar fasciitis and overpronation of bilateral feet. The patient has failed to achieve pain relief with numerous conservative treatment modalities including non-steroidal anti-inflammatory drugs (NSAIDs), over-the-counter orthotics, icing, stretching, and corticosteroid injections. The patients provider has recommended treatment with custom molded foot orthotics. As noted in the medical literature, custom molded orthotics are a mainstay in the treatment of patients with painful plantar fasciitis. Lewis and colleagues found that, Studies have shown that orthotics, both prefabricated and custom fitted, reduce pain and improve function in adults with acute plantar fasciitis with few risks or side effects. The provider noted that this patient has a history of painful plantar fasciitis as well as a pes planus foot structure and over pronation. The requested custom functional orthotics will help to reduce overpronation of the foot as well as support and reestablish a medial arch. These two activities are noted to reduce stress and strain from the plantar fascial origin and reduce plantar fasciitis pain. For these reasons, the requested custom molded foot orthotics are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is licensed D.P.M., board certified in podiatric 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

Findings:  The physician reviewer found that An enrollee has requested reimbursement for Zoll LifeVest provided for three months. This patient sustained an episode of ventricular fibrillation due to acute myocardial ischemia that required resuscitation. Although the patient did sustain a ventricular fibrillation arrest, this was due to myocardial ischemia, which was corrected with surgical revascularization. Post-operatively, the patient was provided a LifeVest wearable cardioverter defibrillator for three months to prevent against sudden cardiac death (SCD). Per the current American Heart Association (AHA) recommendations, the LifeVest wearable defibrillator is a class IIB indication for patients following recent coronary revascularization (Piccini, et al.). The AHA further noted that although wearable cardioverter defibrillator therapy is increasingly used in clinical practice, at present, only preliminary data exist on the actual effectiveness of this intervention in improving survival among patients who are at risk for SCD. Accordingly, the Zoll LifeVest provided for three months 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 Zoll LifeVest provided for three months 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for endoscopic balloon dilation procedure of the Eustachian tubes. This patient presented with a history of nasal and ear congestion, as well as complaints of ear clicking and popping. Treatment with the standard of care has included Flonase, Claritin, and Astelin. Given the lack of symptomatic improvement, the patient underwent balloon dilation of the Eustachian tubes. Treatment options for patients with obstructive Eustachian tube dysfunction such as placement of pressure equalization tubes create an alternative route for ventilation, but do not address the problem at the Eustachian tube and may cause complications. Multiple studies have assessed the short- and long-term efficacy of balloon dilation of the Eustachian tubes (Poe, et al.). Meyer and colleagues randomized 60 patients to undergo balloon dilatation of the Eustachian tubes or continued medical therapy. The authors noted that, Balloon dilation is a safe and effective treatment for persistent Eustachian tube dysfunction. Moreover, the authors concluded that their findings support balloon dilation as superior to continued medical management for patients with persistent Eustachian tube dysfunction. All told, the endoscopic balloon dilation procedure of the Eustachian tubes was 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 endoscopic balloon dilation procedure of the Eustachian tubes was 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 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 reviewers 1, 2, and 3 are board certified in otolaryngology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Guardant360 comprehensive liquid biopsy.Findings:  The physician reviewer found that the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. Shatsky and colleagues explain that clinical-grade next generation sequencing (NGS) of tissue- and blood-derived circulating tumor DNA allows assessment of multiple genomic alterations in patients with cancer and also provides prognostic information. Patients with inflammatory and metastatic breast cancers benefit from NGS to identify markers that may indicate benefit from targeted treatment or clinical trials. Mosele and colleagues report that for hormone receptor-positive/HER2-negative breast cancer, testing for PIK3CA mutations with tumor or liquid biopsy may identify candidates for specific therapies. The National Comprehensive Cancer Network (NCCN) guidelines for invasive breast cancer note that assessing for PIK3CA mutations with tumor or liquid biopsy in patients with HR-positive/HER2-negative breast cancer may identify candidates for therapy with alpelisib plus fulvestrant. In this case, the records did not document that the patient had tissue available for testing. Therefore, Guardant360 comprehensive liquid biopsy was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Guardant360 comprehensive liquid biopsy at issue was 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 likely to have been 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 reviewers 1, 2, and 3 are board 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: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine. Findings:  The physician reviewer found that records document that this patient presents with right upper extremity and facial paresthesias, headaches, and nausea. The patients provider has recommended further evaluation with MRI of the cervical spine. According to the American College of Radiology (ACR) appropriateness criteria for the evaluation of patients with cervical neck pain or cervical radiculopathy, MRI of the cervical spine is indicated for further evaluation of concerning signs and/or symptoms including neck pain or radiculopathy in the setting of trauma, malignancy, prior neck surgery, spinal cord injury, certain systemic diseases, suspected infection, and intractable pain despite therapy. The records provided for review do not include documentation of any concerning signs or symptoms as described by the ACR recommendations. Moreover, the patient does not have any new reported neurological symptoms since previous MRI. The patient underwent a recent MRI of the cervical spine approximately one month ago, which demonstrated no significant findings. In the absence of any new symptoms or indication for the examination, the requested MRI of the cervical spine is not medically necessary for 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 radiology with subspecialty certification 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lidocaine 5% cream. Atopic dermatitis (AD) is a common itchy inflammatory skin disease characterized by immune activation, marked epidermal hyperplasia, and defective barrier function, reflecting underlying alterations in keratinocyte differentiation. The disease may be associated with significant morbidity, particularly when complicated by secondary infection. Frequent disruption of sleep is common, and emotional stress associated with the illness can have a significant impact on quality of life for patients and families. Skin inflammation in atopic dermatitis results from inherited and acquired insults to the skin barrier, and agents that normalize the skin barrier reduce the dependence on topical steroids.  Medical literatures explain that pruritus is a common symptom of AD that may be localized or generalized, and that in addition to physical effects such as skin injury, secondary infections, scarring, and sleep deprivation, pruritus can contribute to emotional disturbances, such as agitation and depression and, in severe cases, may be incapacitating. The authors further explain that while amelioration of pruritus is sometimes easily attained, treatment is challenging in some patients. Researchers report that topical therapy is not only useful but most often necessary to achieve symptom control in chronic pruritus. Researchers note that lidocaine 5% medicated plaster is safe and was effective in the treatment of local neuropathic pain. In this clinical setting, the medical literature supports the use of topical anesthetics, such as lidocaine 5% cream, in the treatment of neuropathic itch for patients with AD. Therefore, lidocaine 5% cream is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested lidocaine 5% cream 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 reviewers 1, 2, and 3 are board certified dermatology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent. Findings: The U.S. Food and Drug Administration (FDA) approves the use of Dupixent, an interleukin-4 receptor alpha antagonist, for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. One study notes that moderate-to-severe atopic dermatitis is defined as involving over 10% of body surface area (BSA) and/or involvement of highly visible areas or those that are important for function such as the hands, neck, face, and genitals, and significantly impaired quality of life. Another study notes that the data supporting the safety and efficacy of the use of dupilumab (brand name Dupixent) in moderate-to-severe atopic dermatitis is substantial. Systemic cyclosporine is contraindicated in those with hypertension and kidney impairment, is immunosuppressive and associated with increased infection risk, and cannot be used long term due to these toxicities. The use of methotrexate, an immunosuppressive, has been associated with increased hospitalization if a patient is infected with COVID-19, and immunosuppressives such as methotrexate, mycophenolate, azathioprine, and cyclosporine may reduce the response to vaccination. In this case, the patient has moderate-severe atopic dermatitis with 24% BSA involvement. They have tried and failed therapy with triamcinolone and clobetasol. In this clinical setting, the use of the requested medication is medically indicated. Therefore, Dupixent is medically necessary for the treatment of this patientFinal Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Synvisc-One (hyaluronan) injection in both knees. Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this patients case, there is a history of lasting benefit from viscosupplementation in the past, and it helped more than any other treatment. There is sufficient support for the requested services in this clinical setting. Therefore, the requested Synvisc-One (hyaluronan) injection in both knees is medically necessary for the treatment of this patient.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.