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

Nature of Statutory Criteria/Case Summary. An enrollee has requested arthroscopic or open ankle surgery repair with bone graft and cartilage allograft for treatment of the enrollees right ankle injury. Findings: Two physician reviewers found that the patient complains of right ankle pain. The patient was snowboarding several months ago and sustained a suspected pronation injury to the right ankle, after missing a jump. The patient noted immediate pain and presented to the emergency department where he was instructed to limit weight bearing and use crutches for a possible hairline fracture. The pain initially resolved, but when he increased his activities, there was an acute increase in his symptoms. The patient was found to have an osteochondral lesion of the talar dome. The diagnosis is listed as osteochondral lesion (fracture) and missing cartilage and bone of the talus. The patient is requesting coverage for arthroscopic or open ankle surgery repair with bone graft and cartilage allograft. The Health Plan has denied the requested services as experimental or investigational for treatment of this patient. There is support in the medical literature for the requested services in this clinical setting. Particulated juvenile articular cartilage allograft transplantation for osteochondral lesions of the talus is known to be an effective method for management of focal chondral defects.  This method relies on the ability of juvenile chondrocytes to migrate from cartilage explants after being secured in a cartilage defect.  Studies have demonstrated that it is a rapid, safe, and effective treatment for cartilage defects.  In light of the foregoing, the arthroscopic or open ankle surgery repair with bone graft and cartilage allograft is likely to be more effective than other modes of therapy for the treatment of this patient.Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in orthopedic surgeon and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested intravenous immune globulin (IVIG) therapy for treatment of the enrollees relapsing remitting multiple sclerosis. Findings: Three physician reviewers found that this patient has relapsing multiple sclerosis and is requesting IVIG therapy for ongoing treatment, not for a relapse, but rather as a disease modifying therapy. While the records document the patient has been treated with interferon and Tecfidera, there are standard U.S. Food and Drug Administration (FDA) approved agents available for multiple sclerosis including Gilenya, Lemtrada, and Tysabri. IVIG is not an FDA approved therapy for the treatment of multiple sclerosis. While there have been many small trials, the results are mixed, and IVIG is not typically included in the options used to treat relapsing multiple sclerosis except for a severe disabling exacerbation not responding to intravenous steroids. At this time, there is a lack of evidence that IVIG is more effective as a disease modifying agent than any of the standard therapies. For these reasons, the requested IVIG is not more likely to be effective for the treatment of this patient than other standard therapies.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 board certified in neurology 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 enrollee, who was asymptomatic. Findings: Two physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and biopsies and increase in detection of small cancers and diagnostic accuracy compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.Final Result: Two of three reviewers determined that the service at issue was 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a dopamine transporter single photon emission computed tomography (DaT-SPECT) scan of the brain. Findings:  Two physician reviewers found that the peer-reviewed medical literature, noted that DaT-SPECT scan has the potential to provide support in diagnosis, especially for those patients who have an unclear presentation of Parkinsonian syndrome. Another study found that DaT-SPECT scan imaging significantly affected the clinical management and diagnosis of patients with clinically uncertain parkinsonian syndrome (CUPS). The authors concluded that DaT-SPECT scan is safe and well-tolerated and is a useful adjunct to differential diagnosis of CUPS. Further, the study reported that DaT-SPECT may help differentiate essential tremor (ET) from parkinsonian syndrome (PS) as an adjunct to other diagnostic evaluations. Thus, the literature does support the use of DaT-SPECT scan to assist in the diagnosis and help guide treatment decisions in patients with suspected parkinsonian syndromes. Final Result: Two reviewers determined that the requested diagnostic procedure 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 Oxycontin for treatment of the enrollees chronic intractable pain syndrome.  Findings: The physician reviewer found that based on the medical literature and the presented clinical records, Oxycontin 60 mg twice per day has not been established as medically necessary. The requested dosage and quantity are excessive in light of the patients condition and in addition to the medication regimen. Such doses and quantity are only indicated for malignant pain. The medical records shows the patient has chronic non-malignant pain. The current standard of care for chronic pain associated with disc herniation or joint disease is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. Based on a study by Mafi and colleagues, there are Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments, except in rare cases, such as acute neurologic compromise or other red flags, including a history of malignant neoplasms. Similar findings are reflected in a report by Karppinen and colleagues which states that Conservative decisions in the treatment of degenerative disc disease are based on interventions made for patients with chronic [low back pain] LBP. There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic LBP Furthermore, these therapies work best in a multidisciplinary rehabilitation context. There are a variety of anticonvulsants and anti-depressants considered adjunctive to pain management therapy. In addition, high dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. Short-acting opiates are likely to cause adverse outcomes. Therefore, Oxycontin 60 mg twice per day is not medically necessary for treatment of the patients medical condition. An appropriate tapering regimen should be implemented to avoid possible untoward effects associated with abrupt cessation of the patients current regimen.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested direct applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder. Findings: The physician reviewer found that in this clinical setting, 30 hours per week of ABA therapy, 10 hours per month of supervision and one visit per week of parent training is medically necessary for treatment of the patients autism. The patient has received high level ABA therapy for a number of years. According to the documentation submitted for review, the patient has met some motor and language goals, but has not met many of the social goals. The patient continues to require a high level of ABA services due to his maladaptive behaviors that include aggression, non-compliance and whining. In addition, the progress reports show an increase in maladaptive behaviors. The Health Plans authorization of 10 hours per week of ABA therapy is not clinically indicated for this patient. Decreasing ABA hours from 40 hours per week to 10 hours per week will likely lead to a return of previous behaviors and a loss of skills. Therefore, 30 hours per week of ABA therapy, 10 hours per month of supervision and one visit per week of parent training (CPT 0370T) is medically necessary for treatment of the patients autism.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Three physician reviewers found that the American College of Radiology (ACR) urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had the exam been done with 2D imaging only. Therefore, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three reviewers determined that the diagnostic procedure at issue was 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Lynparza for treatment of the enrollees stage IV uveal melanoma metastatic to the liver and the lungs. Findings: The physician reviewer found that the medical literature supports the requested medication in this clinical setting. Olaparib is an inhibitor of poly-ADP-ribose polymerase (PARP) that is approved by the U.S. Food and Drug Administration for treatment of ovarian cancer for patients who have failed three prior therapies and tested positive for germline breast cancer (BRCA) mutation. This patients melanoma was found to have a BAP-1 mutation. Lynparza was recommended by the patients provider because BAP-1 is in the same pathway as BRCA1. The use of Lynparza in this patients case needs to be evaluated in the context of molecular targeted therapy. BAP-1 loss of function has been described in renal cell carcinoma, osteosarcoma, and bladder cancer and correlates with olaparib sensitivity (Pena-Llopis, et al; Engert, et al). A study by Harbour and colleagues found that BAP-1 mutations appear to be frequent in uveal melanomas. Recently, the medical research shows that it has become important to identify mutations that may be amenable to targeted therapy. A study of 86 patients was published in the Journal of Clinical Oncology where the progression free survival on regimen selected by molecular profiling was compared to progression free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage (Von Hoff, et al). Similarly, in this case molecular analysis revealed BAP-1 mutation and olaparib is an appropriate genomically-directed therapy. As such, the requested Lynparza is 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 medical 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the cooling device for treatment of the enrollees medical condition status post anterior cruciate ligament (ACL) reconstruction surgery. Findings:  Two physician reviewers found that this patients provider recommended a commercial cold compression unit (VascuTherm2) for post-operative use following knee arthroscopy for degenerative meniscal tearing. However, there is a lack of scientific evidence demonstrating that such devices improve outcomes following such surgery and the devices are not included in any evidence based treatment guidelines. Some studies have suggested short-term pain relief, but no effect on long-term outcomes, while other studies have reported no benefit at all. Risk of DVT and pulmonary embolism is low following arthroscopic partial meniscectomy. Cooling is frequently recommended after surgery, but can be accomplished with available materials such as bags of ice. In the peer-reviewed medical literature, the authors noted that the potential benefits of cryotherapy on blood loss, postoperative pain, and range of motion may be too small to justify its use, and the quality of the evidence was very low or low for all main outcomes. Based on the available scientific evidence, the cooling device provided was not more likely to be more beneficial for treatment of this patients post-operative medical condition than more standard treatment such as a compressive bandage and cooling with bags of ice. Final Result: The reviewers determined that the device 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency ablation for treatment of the enrollees degenerative disc disease and facet arthropathy. Findings: The physician reviewer found that the records provided for review document that this patient has a history of cervical degenerative disc disease and spondylosis. The patient previously underwent cervical facet radiofrequency lesioning in 2015 with greater than 50% pain relief for seven months. Currently, the patients pain is not responsive to conservative measures including a medication regimen consisting of high dose opioids. In the medical literature, Cohen and colleagues found that Radiofrequency denervation provides some benefit for up to a year in approximately 60% of individuals. Since this patient previously responded well to radiofrequency lesioning, the requested radiofrequency ablation is supported as medically necessary for treatment of her medical condition.Final Result: The reviewer determined that requested service 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 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: 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 risk for breast cancer. Findings: Three physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that 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 was 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested medication nivolumab Opdivo for the treatment of the enrollees metastatic cervical cancer with metastasis to liver and lungs.  Findings: The physician reviewer found that there is a lack of clinical data in the medical literature to suggest that treatment with Opdivo offers a superior benefit as compared to conventional therapy for metastatic cervical cancer. The standard of care for metastatic cervical cancer is chemotherapy with or without biologic therapy as listed and summarized in the National Comprehensive Cancer Network guidelines. This drug is currently in clinical trials for this disease but there is a lack of reported randomized phase II or phase III trials showing a progression free or overall survival benefit in metastatic cervical cancer. Therefore, nivolumab remains an unproven benefit and is considered off label. As such, the requested medication nivolumab is not likely to result in a superior clinical outcome as compared to standard therapy for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification in medical 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.