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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Epidiolex 100 mg. Currently, Epidiolex is the only U.S. Food and Drug Administration (FDA) approved medication for use as adjunct therapy in patients with Dravet syndrome or Lennox-Gastaut syndrome (LGS). However, the trials evaluating the safety and effectiveness of Epidiolex only evaluated patients with these two specific seizure disorders. Epidiolex has not yet been critically evaluated for use in any other form of epilepsy, nor has it been evaluated for use as monotherapy. A query of clinical trials reveals that there are multiple ongoing studies involving Epidiolex to evaluate its efficacy and safety in other seizure disorders. This patient has a seizure disorder, but there is no documentation of LGS or Dravet syndrome. Given the absence of published literature available to support the use of Epidiolex for patients with seizure disorders other than LGS and Dravet syndrome, the requested drug Epidiolex 100 mg is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in sleep 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 Keytruda.Findings:  Three physician reviewers found that there is a lack of support for the requested medication in this clinical setting. Based on the records, this patient has stage IIIB non-small cell lung cancer. He was offered appropriate therapy based on this stage, including chemoradiation followed by durvalumab maintenance therapy. Use of single agent pembrolizumab (Keytruda) is not approved by the U.S. Food and Drug Administration for initial therapy of stage III non-small cell lung cancer.  Pembrolizumab is only approved for single agent therapy of metastatic/stage IV non-small cell lung cancer demonstrating sufficient programmed death-ligand 1 (PD-L1) expression. The use of Keytruda as a single agent to treat stage III non-small cell lung cancer has not been demonstrated to be more beneficial than standard therapy. Therefore, Keytruda is not likely to be more effective than other treatment options.Final Result: The reviewers 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: 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

An enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation therapy. 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. Sheets and colleagues evaluated the comparative effectiveness of intensity modulated radiation therapy, proton beam radiation therapy, and conformal radiation therapy for prostate cancer. In the comparison between intensity modulated radiation therapy and proton beam radiation therapy, intensity modulated radiation therapy patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between intensity modulated radiation therapy and proton beam radiation therapy. A position statement released by the American Society of Radiation Oncology (ASTRO) in 2013 stated, 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. The comparison plan between the photon and proton plans demonstrated no clinical benefit with the proton dosimetry. Therefore, proton beam radiation therapy was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Phenergan. The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient reports chronic nausea with a history of chronic gastritis. Possible etiologies of her nausea include migraine headaches and medications, including opiate analgesics. The patient has requested continued use of Phenergan for her symptoms, and her provider has noted that this medication has increased risk of potentially harmful side effects. The treatment of chronic nausea should include a thorough history and physical examination. There should be an attempt to discover the etiology of the nausea, including as a side effect of other medications. Testing should be guided by the symptom duration and characteristics of symptoms. Targeted treatment should be provided. Although Phenergan is an antiemetic that may partially alleviate acute nausea and vomiting, there is a risk of hypotension and extrapyramidal side effects. In this case, the patient is requesting a potentially harmful drug for the treatment of chronic nausea that has not been clearly defined or investigated. Her provider has offered an alternative medication with a safer side effect profile, Zofran. Furthermore, it is possible that the nausea is due to opiate use, in which case a taper from this medication would be appropriate to try to treat and prevent further nausea. Therefore, Phenergan is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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 enrollee has requested reimbursement for the high intensity focused ultrasound (HIFU) prostate ablation procedure that was performed. The Health Plan has denied the services at issue as investigational for treatment of the enrollees prostate cancer.Findings:  Three physician reviewers found that high-intensity focused ultrasound (HIFU) has been widely used for whole gland ablation. The first published results of focal HIFU are promising. The patient's quality of life and potency are well preserved with good early results. Whole-gland HIFU is a repeatable day-case treatment that confers low rates of urinary incontinence. Disease control at a median of just under five years of follow-up demonstrates its potential as a treatment for nonmetastatic prostate cancer. Endoscopic interventions and erectile dysfunction rates are similar to other whole-gland treatments. The U.S. Food and Drug Administration (FDA) has approved HIFU as safe for the treatment of prostate ablation. However, there is no specific indication for the treatment of prostate cancer. Furthermore, the safety and efficacy of chemical or surgical cytoreduction of the prostate remains unproven. The safety and efficacy of HIFU are currently being evaluated. There is a paucity of long-term comparative clinical trials indicating that this form of treatment is superior to conventional treatment options. Thus, the HIFU prostate ablation procedure that was performed 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 requested procedure was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a female with a diagnosis of symptomatic uterine fibroids. She has complaints of heavy periods with clots. A transabdominal ultrasound revealed the uterus is anteverted measuring 14 cm with a large 13 cm calcified fundal uterine fibroid. She was referred to an interventional radiologist for fibroid embolization.The patient has been diagnosed with uterine fibroids by pelvic ultrasound, and has symptoms of fibroids, including heavy menstrual bleeding, menstrual cramping, and pelvic pain. These symptoms can significantly decrease quality of life. Other standard treatment options for symptomatic uterine fibroids include hysterectomy or myomectomy. Hysterectomy often requires hospitalization and a long recovery time. In addition, not all patients are considered candidates for myomectomy. These specific symptoms are the target of treatment by uterine artery embolization. Therefore, the uterine artery embolization is medically necessary for 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 interventional and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether the allergen-specific testing,  that was provided was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy. The patient presented for complaints of ongoing and intermittent abdominal soreness, diarrhea, bloating, and back pain. She also reported anxiety, closing throat, and palpitations. She described these symptoms as worsening with eating. The symptoms first occurred approximately two months prior after starting naturopathic hormone treatment.Findings:  Three physician reviewers found that the medical records fail to demonstrate allergic immunoglobulin E (IgE) type reactions to foods or a causal association with a specific food type.  The two major recent practice parameters posted by the National Institute of Allergy and Infectious Diseases (NIAID) and American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology (AAAAI/ACAAI) Joint Task Force see immunoglobulin G (IgG) food testing as non-validated and do not recommend this form of testing. Blood tests for food allergies demonstrate positive test results in normal, non-food allergic people. As such, allergen-specific testing, that was provided was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the requested test is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in allergy and immunology 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: At issue is whether fetal chromosomal microdeletion genomic sequence analysis circulating cell-free fetal deoxyribonucleic acid (DNA) in maternal blood that was provided was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy.  Findings:  Two out of three physician reviewers found that the American College of Obstetricians and Gynecologists (ACOG) endorsed first-trimester screening. It is considered medically necessary for women age 35 or older to have special testing for fetal health. Non-invasive prenatal screening (NIPS) is more accurate and allows for timely results at the earliest period of gestation. This patient is considered high risk due to her age, and she would need to be closely followed as a high-risk pregnancy for her own health and the health of her fetus. The fetal chromosomal microdeletion genomic sequence analysis circulating cell-free fetal deoxyribonucleic acid (DNA) in maternal blood that was provided was likely to have been more effective than other methods of evaluating this patient. The fetal chromosomal microdeletion genomic sequence analysis at issue was likely to have been more beneficial for the evaluation of the patients pregnancy than other available modalities.Final Result: Two out of three reviewers determined that the requested test 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.One out of three physician reviewers found that given the limitations of cell-free DNA screening performance, conventional screening methods remain the most appropriate choice for first-line screening for most women in the general obstetric population. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in clinical biochemical genetics 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: At issue is whether the occipital nerve block therapy that was provided was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy. The enrollee was diagnosed with chronic migraine headache, occipital neuralgia, lesser occipital nerve, and TMJ disorder. Bilateral occipital nerve blocks were performedTwo out of three physician reviewers found that occipital nerve block therapy is a common outpatient procedure performed by pain specialists and headache specialists for a variety of indications, including migraine and occipital neuralgia. This patient has migraines, possibly chronic migraines, and has been diagnosed with occipital neuralgia.  The medical literature supports the services at issue in this clinical setting. Consensus guidelines are also supportive of the use of this procedure. Therefore, the provided occipital nerve block therapy was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy. One out of three physician reviewer found that the evidence on the use of GONBs remains weak.Final Result: The reviewers determined that the requested occipital nerve blocks were likely to have been 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 reviewers 1, 2 and 3 are 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: At issue is whether the feeding therapy with sensory integration services that were received were likely to have been more beneficial for treatment of the patients condition than any available standard therapy. A review of the record indicates that the patient has been diagnosed with autism, anxiety, and sensory integration dysfunction. The severity of his sensory aversion and anxiety surrounding food limits his nutrition.One of three physician reviewers found that The American Academy of Pediatrics states that parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive. Researchers performed a meta-analysis and systematic review of the literature on sensory integration therapy. The authors found that the evidence is insufficient to draw conclusions regarding multisensory activities. Therefore, the feeding therapy with sensory integration services that were received was not likely to have been more beneficial for the treatment of the patients medical condition than any standard available therapy. Two out of three physician reviewers found that in this case, learned behaviors that adversely impact ingestion must be approached by modifying the sensory experience itself, which is addressed during sensory integration. Thus, the feeding therapy with sensory integration services that were received were likely to have been more beneficial than any standard available therapy.Final Result: The reviewers determined that the requested test 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: Two physician reviewers are board certified in neurology with special qualification in child neurology, and one physician review is board certified in pediatrics, all three 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 positron emission tomography (PET) with computed tomography (CT) skull-thigh; CT of the abdomen and pelvis, and CT of the thorax with dye.As noted in the current medical literature, PET/CT is a valuable imaging modality in prostate cancer. The primary role for PET/CT is for restaging of patients with biochemical recurrence after radical prostatectomy or external beam radiotherapy. A study is quoted, Gleason score and PSA value, doubling time, and velocity, can influence positivity of PET/CT. Further, Researchers reported that PET/CT is useful in well selected patients. The authors found that the risk factors for patients with positive PET/CT findings included those with a PSA over 3.0 ng/mL, no early radical prostatectomy, and a Gleason score of 8 or greater. This patient does not meet the criteria for PET/CT based on the available documentation. The records report a history of Gleason score 4+3=7 prostate cancer status post radical prostatectomy with a PSA of 1.1 ng/mL. Initial conventional imaging including bone scan and CT scan remain the gold standard. Therefore, the requested CT of the abdomen and pelvis is supported as medically necessary for evaluation of this patients current medical condition and for staging of his prostate cancer. A CT of the thorax is not within the current standard of care for patients with prostate cancer. Thus, the requested PET with CT skull-thigh and CT of the thorax with dye are not medically necessary for this patients medical condition.Final Result: The reviewer determined that some of the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in urology 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.