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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bronchial thermoplasty for treatment of her medical condition. Findings:  Two physician reviewers found that there is sufficient support for the requested services in this patients case.  The current medical evidence supports the short-term and long-term benefits of bronchial thermoplasty in this clinical setting.  This patient is on an aggressive regimen for control of her asthma and associated conditions, and she has achieved little in the way of adequate control.  Given that prior interventions have not controlled the patients symptoms, bronchial thermoplasty is the appropriate next step in management.  In sum, the requested bronchial thermoplasty is likely to be superior over other treatment options. Final Result: Two reviewers determined that the requested services are 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease and are actively practicing. All three 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 proton beam radiation therapy for treatment of her medical condition.   Findings:  Two physician reviewers found that the difference between proton and photon irradiation is that the protons stop abruptly in the tissue (Bragg Peak) so there is less exit dose through normal tissue. The use of proton therapy is an accepted radiation technology, that has proven efficacy and tolerability as it is simply another means to deliver radiation. Certain conditions such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system (CNS) malignancies are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. There is abundant data on proton therapy for sinonasal cancers as well, and proton therapy is an accepted treatment modality. While proton therapy is not an accepted standard outside of sinonasal cancers abutting critical structures or in the setting of re-irradiation of targets abutting critical CNS structures, both of these situations apply in this patients case. In general, proton therapy is more effective in sparing the normal tissues in and around the base of skull. Thus, the requested proton beam radiation therapy is likely to be more beneficial in treating this patients squamous cell carcinoma than any other available standard therapy.  Final Result: Two reviewers determined that the requested services are 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:  All three reviewers are board certified in radiation oncology and are actively practicing. All three 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 MammaPrint testing for evaluation of her medical condition. Findings: Two physician reviewers found that the MammaPrint 70-gene assay was designed to determine prognosis regardless of hormone status.  It is used by some providers as an adjunct to Oncotype DX when patients fall in the intermediate range and more information is needed to help guide chemotherapy decision making.  It is used to help identify patients with a low risk of recurrence despite high risk clinical features.  MammaPrint results have been validated in several clinical trials.  In this patients case, the use of MammaPrint is likely to be more beneficial to further guide the risk of recurrence than other methods of evaluation. Final Result: Two reviewers determined that the requested services are 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three 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 Mekinist for treatment of her medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the requested medication in this patients case.  Mekinist is one of a newer class of drugs.  It has been found to be beneficial when combined with another drug, in the treatment of metastatic melanoma, in patients with a specific BRAF mutation (V600 mutation).  However, there is a lack of published literature relevant to the use of Mekinist in ovarian cancer. In the absence of such data, and also considering that this patient does not appear to have a BRAF mutation, the use of Mekinist is not likely to be of benefit.  Therefore, Mekinist is not likely to be of greater benefit than other treatment options.  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:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three 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 proton beam therapy for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There is a lack of medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for breast cancer.  Standard treatment with photon radiation is associated with a very low risk of toxicity.  There is no data submitted that suggests that treatment with proton techniques will be able to improve sparing of the skin, heart, and/or lungs compared to standard breast radiation with photon techniques.  Consensus group guidelines do not support the use of proton therapy in this setting.  The current medical evidence does not support the requested services in this patients case.  All told, proton beam therapy is not medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested fusionless spine surgery (pediatric spinal tethering for treatment the enrollees medical condition.    Findings:  Two physician reviewers found that fusionless spine surgery (pediatric spinal tethering) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of sufficient support in the peer-reviewed literature for the requested services in this clinical setting. According to Samdani and colleagues, vertebral body tethering offers a fusionless treatment option for skeletally immature patients with adolescent idiopathic scoliosis. However, the study concluded that longer term follow-up of this cohort will reveal the true benefits of this promising technique. Moreover, anterior of posterior fusion scoliosis surgery remains the gold standard scoliosis procedure at this time. In sum, there is a lack of long-term outcomes data to determine the safety and efficacy of fusionless scoliosis surgery. In addition, complications and long-term outcomes remain unknown.   Final Result: Two 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: One reviewer is board certified in pediatrics and is actively practicing. Two reviewers are board certified in orthopedic surgery and are actively practicing. All three 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 Norco for treatment of her medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the medical necessity for Norco has not been established. According to Peppin and colleagues, several prominent guidelines recommend that patients on long-term opioid therapy have periodic urine drug monitoring to ensure appropriate use. In this case, the patient presents with multiple medical issues including chronic low back pain, ADHD and fibromyalgia. She failed a recent urinary toxicology. Given the inconsistencies in urinary toxicology, enrollment in a pain management program, psychological follow-up is indicated prior to providing Norco. Given the above, the requested medication is not medically necessary for treatment of the 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 anesthesiology with sub-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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a consultation and surgery with a weight loss surgeon for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested services. Based upon the records provided, the patient does not present with morbid obesity (BMI of 40 or greater) or clinically severe obesity (BMI of at least 35 with serious co-morbid conditions). The patient underwent gastric bypass in the past, however there is no documented complication of the original procedure that requires surgical intervention. Moreover, there is no documentation of compliance with any form of post-operative dietary and behavioral follow-up. All told, the requested services are not medically necessary for treatment of the patients medical condition. 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 surgery and has completed a fellowship in minimally invasive/bariatric 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested an electric powered wheelchair for the treatment of his medical condition.  Findings:  The physician reviewer found that the requested equipment has not been established as medically necessary for treatment of the patients medical condition. A power wheelchair has been requested to assist with mobility outside the home. Documentation indicates that a power wheelchair will allow improved community participation. Prior to consideration of a powered wheelchair, planning and evaluation is required to determine if he can safely use the equipment, and if it will be compatible with his abode and transportation methods. A plan for implementation of a powered wheelchair has not been documented. The patient is legally blind and must be able to safely use the device, have means of transport, and have an accessible abode. In addition, the patient has a personal mobility deficit that can be adequately addressed with a walker in the home environment. The patient is able to propel a manual wheelchair. Moreover, he will benefit from a walker with seat. The walker or manual wheelchair should meet his needs for community mobility. All told, the request for an electric powered wheelchair is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested urgent care services on an emergent basis or urgent basis.  Findings:  The physician reviewer found that upon review of the submitted medical records, the patient presented with a moderate sore throat with the onset a short time prior. Although the patient rated her pain at 9/10, there was also documentation noting 5/10 pain rating. In addition, the patient was not experiencing a fever or difficulty swallowing or breathing. The patient had not taken any medication prior to her arrival at the urgent care center. Her vital signs were normal and the patient was not in any distress. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care. Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with symptoms of a sore throat that had commenced gradually. The patient did not have a fever or difficulty swallowing or breathing. The patient had not taken any medication prior to her arrival at the urgent care center. In addition, her heart sounds were regular and her lungs were clear. A rapid strep screen was negative for beta hemolytic strep. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Klonopin for treatment of his behavioral health conditions. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this patients case.  Benzodiazepines possess an array of potential side effects.  Disinhibition, cognitive dulling, perceptual disturbances and exacerbation of depression are common.  Additionally, there is growing concern of misuse, tolerance and dependence issues with this medication class.  As such, contemporary practice standards aim to minimize benzodiazepine therapy and optimize treatment alternatives.  This patient has been evaluated by two psychiatrists.  The first provider tapered the clonazepam, the second provider did not prescribe the medication.  The patient elected to not continue with intensive outpatient therapy to address his anxiety.  The frequency, duration and specific modalities of his current psychotherapy is unclear.  This is particularly significant as the best outcomes emerge from an evidence-based psychotherapy, which represents a first-line intervention for both depressive and anxiety disorders.  Additionally, the patient has not exhausted reasonable pharmacologic strategies to address his illness burden.  Doxepin is a sedating tricyclic medication used for insomnia, mood and anxiety.  Bupropion is a trusted noradrenergic-enhancing antidepressant. Having been initiated on both at conservative doses recently, the impact of the medication trials on the symptom complex is not yet declarative.  In sum, based on the documentation provided, it appears that the patient has not exhausted well-supported medication and non-pharmacologic treatment alternatives to address his depression and anxiety.  Therefore, the requested Klonopin is not medically indicated 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi for treatment of his hepatitis C virus. Findings:  The physician reviewer found that the position of American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommend that all patients with chronic hepatitis be treated except those with limited life expectancy of 12 months or less due to a non-liver related condition. In the past, treatment for patients with early stage hepatitis C virus (HCV) was delayed in order to wait for more effective, less toxic treatment. This has now changed as sofosbuvir (Sovaldi) plus ribavirin achieves 98% cure rate in patients with genotype 2 and has no serious adverse effects or contraindications. The U.S. Food and Drug Administration (FDA) label is clear on its approved uses which includes early stage disease. Moreover, the position of the AASLD on HCV does not stratify patients based on early or late stage disease. Therefore, per the guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage. For these reasons, the requested treatment with Sovaldi is supported as medically necessary for the treatment of this patients hepatitis C infection.  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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were 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. All three 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.