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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hip surgery  surgical release of femoroacetabular impingement syndrome, also known as FAIS (hip arthroscopy with labral repair and hip arthroscopy with femoroplasty) for the enrollees left hip lateral tear. Findings:  The physician reviewers found that In this case, the patient had insidious onset of symptoms for about six months prior to surgical treatment.  There is documented evidence of a failed conservative management program to include intraarticular corticosteroid injection, activity modification and a formal course of physical therapy. The record documents well preserved joint space and radiographic findings consistent with femoroacetabular impingement. The patient underwent a surgical procedure which resulted in good improvement of his symptoms and an increased activity level. Moreover, there are a lack of reasonable alternative interventions which have been shown to be more efficacious than the surgical procedure at issue. For the reasons provided, the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in orthopedic surgery and 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 parent of a patient has requested reimbursement for a DOC band helmet for treatment of the enrollees severe plagiocephaly and torticollis. Findings:  The physician reviewer found that cranial orthoses may be considered for patients with post cranial vault remodeling surgery for synostosis, moderate to severe non-synostotic plagiocephaly or brachycephaly when the patient is at least three months but not greater than 18 months of age with documented trial of conservative treatment, documentation of cranial asymmetry demonstrated by skull base asymmetry greater than or equal to 6 mm, cranial vault asymmetry greater than or equal to 6 mm, orbitotragial depth asymmetry greater than or equal to 6 mm, and a cephalic index/ratio two standard deviations above or below the mean for gender and age. The initial Star helmet provided to this patient was not appropriate to the patients medical needs for correction of her plagiocephaly. A DOC band was specifically recommended by her treating neurosurgeon. Appropriately fitted cranial molding helmets have been demonstrated to be effective at correcting the skull deformity in infants with positional plagiocephaly. Final Result: The reviewer determined that the device at issue was 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 pediatrics with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for knee replacement surgery. Findings:  The physician reviewer found that in the medical literature, a study  concluded that a BMI greater than 40 kg/m2 may be used as a cutoff to help guide patient education and treatment options for primary total knee arthroplasty. Another study observed an increased risk of wound infection and deep vein thrombosis in obese patients. Study results did not advocate surgery be given without consideration of BMI, but indicated that universal denial of surgery based on BMI is unwarranted. This patient presents with chronic bilateral knee pain, right greater than left. Clinical examination findings are consistent with radiographic evidence of severe joint space narrowing in the medial and lateral compartments of both knees, right more severe than left, and moderate degenerative changes in the patellofemoral joint. There is detailed evidence of conservative treatment, including activity modification, medications, home exercise, attempted weight loss, and corticosteroid injections without sustained improvement. However, the patients current BMI is documented as greater than 50 kg/m2. Additional comorbidities include atrial fibrillation, chronic obstructive pulmonary disease, and hypertension. Overall, there is no compelling rationale presented to support the medical necessity of total knee replacement in a patient with a BMI over 50 kg/m2. Therefore, the requested knee replacement surgery is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an automated insulin delivery device for treatment of the enrollees type 1 diabetes. Findings:  Two physician reviewers found that Continuous glucose monitoring systems including real-time systems have U.S. Food and Drug Administration (FDA) approval. However, they are not the subject of Phase I-III clinical trials. The American Diabetes Association position statement on standards of medical care in diabetes states that CGM may be a supplemental tool to [self-monitoring of blood glucose] SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes. The Medtronic is a partially automated, closed-loop hybrid system to deliver insulin. It is a hybrid system (not fully automated), in that only the basal insulin doses are automatically adjusted depending on CGM results. Patients need to manually request prandial insulin doses. Although the preliminary results for partially automated, closed-loop system are promising, additional large scale long term trials are need. A study evaluated the safety of a hybrid closed-loop system in patients with type 1 diabetes. The authors concluded that, Longer-term registry data and randomized studies are needed to further characterize the safety and efficacy of the hybrid closed-loop system. At this time, the incremental benefit of automated closed-loop control of insulin administration is unclear. There is a lack of long term data available demonstrating health outcome benefits of such technology compared to other treatment methods, including multiple daily injection therapy and continuous insulin infusion therapy with or without a threshold suspend device with or without CGMS. The requested device, Medtronic lacks long term studies showing it is benefit for the treatment of patients with type 1 diabetes. Final Result: The reviewers determined that the requested device 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 reimbursement for residential treatment center level of care services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient did not have a comorbid psychiatric illness, protracted withdrawal syndrome or medical condition that would have necessitated the delivery of care in a residential treatment setting.  He was physically healthy and not taking medication.  He was motivated in his quest for sobriety.  At the start of the timeframe in dispute, the patient had completed 30 days of residentially-based treatment, the duration of which is consistent with community practice standards.  He had planned to attend an intensive outpatient program.  Further, the patient had no prior history of community programming, outpatient drug and alcohol counseling, anti-craving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment. This is significant since modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. Moreover, there was no documentation to suggest that comprehensive, evidence-based services provided a less restrictive setting would have been inadequate after an uncomplicated detoxification and 30-day course of residential treatment. Thus, residential treatment center level of care services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cabometyx 60 mg for treatment of the enrollees metastatic gastrointestinal stromal tumor. Findings:  The physician reviewers found that Cabometyx is an oral inhibitor of tyrosine kinases, including MET, VEGFR, and AXL. Cabometyx has been approved for use in renal cancer and medullary thyroid cancer. A genetic analysis reveals that this patients cancer cells have mutations in KIT exons 11 and 17. According to the genetic analysis, the mutation in exon 17 suggests sensitivity to tyrosine kinases, but this is not very specific as to Cabometyx sensitivity. There is a lack of data suggesting sensitivity of GIST to this drug. The medical evidence does not support the requested medication in this clinical setting. All told, Cabometyx 60 mg is not likely to be superior over other available treatment options. Final Result: Two of three 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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 authorization and coverage for transcranial magnetic stimulation for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder. However, the recommendation does not extend to personality disorders or bipolar disorder. Although some preliminary positivism regarding the application of transcranial magnetic stimulation therapy for patients with bipolar disorder can be found in the medical literature, there is an absence of well-controlled and adequately powered exploratory and confirmatory studies. The medical evidence does not support the requested services in this clinical setting. All told, transcranial magnetic stimulation 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) procedure for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. The procedure is approved by the American Psychiatric Association (APA) for the treatment of acute phase depression in the adult population. A typical treatment course of TMS consists of 30 to 40 sessions spanning four to six weeks. According to the TMS treatment recommendations by researchers The standard parameter setprovided clinical benefit in treatment courses up to 6 weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The article suggested that an extended treatment course of one to two weeks may be appropriate for patients who experience only partial improvement and the clinician believes that a clear plateau of benefit has not been obtained. In this case, the patient had already utilized this additional time frame.  Moreover, there is a lack of adequately powered, controlled studies showing the benefit of longer courses of TMS therapy. Thus, the medical literature does not support a reasonable expectation that additional TMS therapy at the time would have improved the patients condition or prevented a more serious episode of illness. Further, there is a lack of evidence in the literature to suggest that the patients marginal improvement was likely due to the additional TMS sessions, as the patients daily cannabis use may have been contributing to the suboptimal response. In addition, the patient was neither prescribed antidepressant medication nor active in psychotherapy at the time of treatment with TMS, which represented first-line interventions in the treatment armamentarium for major depressive disorder. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acupuncture services for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The documentation does not include a pre-acupuncture evaluation reporting the functional-motor-sensory deficits the patient had that needed to be addressed by an acupuncture trial. Ten acupuncture sessions were already completed without documentation of measurable, significant gains. Although the patient reported that acupuncture services had been beneficial, the records do not document sustained, significant, objective, functional improvement obtained with previous acupuncture. The medical evidence does not support the services at issue in this clinical setting. All told, acupuncture services were not and are 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 oriental 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: An enrollee has requested authorization and coverage for acupuncture services for treatment of the enrollees chronic neck and back pain. Findings:  The physician reviewer found that The physician reviewer found there is sufficient support for the requested services in this clinical setting. Given that the patient continues to be symptomatic with complaints of chronic, severe lower back and neck pain, an acupuncture trial for pain management and improvement in function is medically appropriate. A study concluded that adequate acupuncture treatment may reduce chronic pain in the neck and shoulders and related headache, and the effect lasted for three years. Researchers reported that acupuncture has been found to be more effective than no treatment for short-term pain relief in chronic low back pain. 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 oriental 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: An enrollee has requested authorization and coverage for heart procedure (electrophysiological study and catheter ablation) for treatment of the enrollees history of premature ventricular contractions. Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the requested services.  The PVC ablation is medically necessary in this case. The medical studies show that frequent PVCs can be associated with a cardiomyopathy. Catheter ablation is considered if there is failure or intolerance to medical therapy, a single PVC morphology noted, and probable reversible left ventricular systolic dysfunction due to PVCs. These conditions are documented in this patient. The patient has symptoms of frequent palpitations due to premature ventricular complexes and palpitations were reported to occur several times a day. An EKG showed PVCs in a pattern of bigeminy. A Holter showed 18% of beats to be PVCs. His symptoms and arrhythmia persisted despite metoprolol. Catheter ablation is indicated for the PVC focus. As such, the heart procedure (electrophysiological study and catheter ablation) is medically necessary for the treatment of this patients medical condition. 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 internal medicine with sub-specialty certification in cardiovascular disease and clinical cardiac electrophysiology 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 Epclusa for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.