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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued physical therapy, three times per week with an emphasis on balance and proprioception. Findings:  The physician reviewer found that There is sufficient support in the medical literature for the requested services in this clinical setting.  The medical records indicate that the request at this time is for additional physical therapy with an emphasis on balance and proprioception. This patient fractured the distal tibiofibular joint in spring of 2017. The records note that the patient required surgery to strengthen her ankle. The provider noted without a walker, the patients gait was less steady and the patient took shorter strides. The left ankle dorsiflexion was prone, 5 degrees. The provider noted that the patients gait with the walker was less steady and she was only able to take shorter strides.  The patients gait with a quad cane was slow and the patient was still unsteady. The left ankle dorsiflexion was prone, 5 degrees. The patient is participating in physical therapy but based on the records, she has made slow progress in a land based therapy. The standard of care, in this clinical setting, supports physical therapy three times per week. The patient states she continues to have functional limitations, as balance is an issue. Physical therapy once per week would be insufficient for a patient who is not yet independent. Additionally, physical therapy with an emphasis on balance and proprioception is also supported in this patients case. Aquatic therapy is a treatment option that is well supported in the medical literature as an alternative form of treatment to address limitations of land based therapy. There are some risks involved with land based gait/proprioception training such as falling during training.  For these reasons, continued physical therapy, three times per week with an emphasis on balance and proprioception is medically necessary for treatment of this patient at this time.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 physical medicine and rehabilitation 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 advanced lipoprotein testing. Findings:  The physician reviewer found that despite some researchers advocating for use of the advanced lipoprotein analysis, the American College of Cardiology (ACC) guidelines do not support use of the advanced lipid testing. Rather, these guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. In addition, the guidelines have moved away from specific target values. Instead, they emphasize use of the pooled risk score analysis for decisions regarding statin therapy. These guidelines are formulated based on thorough review of current literature. Accordingly, the advanced lipoprotein testing was not likely to have been of greater benefit over the standard lipid panels for the evaluation of this patient. Final Result: All three reviewers determined that the services at issue were 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 & 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 coverage for an increase from #30 per month of carisoprodol (Soma) 350 mg to #60 per month of carisoprodol (Soma) 350 mg for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. The recommended maximum duration of use of carisoprodol is up to two to three weeks. This medication is indicated for relief of discomfort associated with acute, painful, musculoskeletal conditions. It is not appropriate for chronic use. In this patients case, the risk of side effects outweighs the potential benefits of this treatment. The current medical evidence does not support the requested medication quantity in this clinical setting. All told, the requested increase from #30 per month of carisoprodol (Soma) 350 mg to #60 per month of carisoprodol (Soma) 350 mg is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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: An enrollee has requested authorization and coverage for Zepatier 50 mg-100 mg for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 reimbursement for the gene test (fetal DNA testing) for evaluation of the enrollees pregnancy. Findings:  Three physician reviewers found that the gene test (fetal DNA testing) performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine recommended cell free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. In this case, the patient is 35 years old and the aneuploidy risk for this patient in this pregnancy warrants cell free DNA testing for aneuploidy. Final Result: The reviewers determined that the testing 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: Reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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 reimbursement for dopamine transporter single photon emission computed tomography (DaT SPECT) scan for evaluation of the enrollees tremor. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this patients case. The diagnostic accuracy of DaT SPECT scans for detecting nigrostriatal cell loss in patients with Parkinsons disease is approximately 98%. It cannot differentiate between various parkinsonian syndromes. However, this modality is diagnostically and therapeutically helpful in the differential diagnosis of essential tremor versus Parkinson tremor. The treatment is fundamentally different in these two diagnoses. In this case, DaT SPECT scan provided the necessary data for treatment planning. Therefore, DaT SPECT scan was likely to have been more effective than other methods of evaluating this patient.  Final Result: The reviewers determined that The 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: 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: The patient has requested reimbursement for the Integra for treatment of the enrollees systemic sepsis and necrotizing fasciitis. Findings:  Two physician reviewers found that This patient presented with a significant complex situation as the result of necrotizing fasciitis. She underwent multiple debridement and required extensive reconstruction. As part of this reconstruction, she underwent Integra placement followed by later skin grafting. Integra is used in these types of situations when there are extensive wounds, similar to burn wounds. As noted by researchers, Integra was used in the management of a variety of wounds, including necrotizing fasciitis, extremity degloving injury, meningococcemia, Marjolin ulcer, post-burn lip reconstruction, and fourth-degree burns with exposed bone or tendon. Engraftment rates of Integra and autograft were 98% +/- 4% and 97% +/- 4%, respectively. All areas of graft loss healed without need for regrafting. The benefits of Integra in the management of acute burn wounds can be extended to other traumatic and complex wounds. Standard therapy would include skin grafting without Integra. However, given this patients extensive wounds, the use of Integra allows for thinner skin grafts and/or stabilization of the wounds for later skin grafting. Final Result: The reviewers determined that the service 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: Reviewers 1, 2 and 3 are board certified in plastic 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test received.  Findings:  The physician reviewers found that there are multiple peer reviewed scientific articles indicating the benefits of the genetic test in thyroid nodules. The test is ordered by providers after analysis of the patients cancer risk based on clinical data, diagnostic imaging features and cytology report. The test is in vitro, which confers no physical risk to the patient. The sample is obtained at the same time of the fine needle aspiration biopsy and no additional procedure is needed. This is the patients second biopsy of the 2 cm thyroid nodule. According to the Bethesda system and American Thyroid Association (ATA) guidelines, the risk of malignancy in FLUS is up to 15%. According to the recent guidelines from the American Thyroid Association, this patients nodule is of low suspicion for cancer, given that its size is under 10 mm. The first biopsy was consistent with a follicular neoplasm. The second time, the cytopathology of the 2 cm thyroid nodule was consistent with a follicular neoplasm. Therefore, it was sent to Afirma for gene expression classifier test. The risk of malignancy is 15 to 30% in follicular neoplasm nodules. The 2015 American Thyroid Associations guidelines state that for follicular neoplasm nodules, molecular testing may be used to supplement malignancy risk assessment data in lieu of proceeding directly with surgery. Informed patient preference and feasibility should be considered in clinical decision-making. The test is also included in the algorithm for diagnosis of thyroid nodules by the National Comprehensive Cancer Network (NCCN) 2016 guidelines. In this case, the result of the gene expression classifier was benign. A benign test result may prevent unnecessary surgery. For this patient, conservative observation may continue versus diagnostic thyroidectomy. Therefore, gene test received was likely to be more beneficial for the evaluation of the patients medical condition than other available standard approaches for the evaluation of this patients medical condition.Final Result: Two of the three the reviewers determined that the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal fusion for treatment of the enrollees back pain. Findings:  The physician reviewer found that the request for lumbar spinal fusion is medically necessary for treatment of the patients medical condition. The peer-reviewed literature supports lumbar decompression surgery for symptoms and findings that confirm the presence of radiculopathy and correlate with clinical examination and imaging findings. Single level lateral lumbar interbody fusion for the treatment of adjacent segment disease is supported as safe and effective. The inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. In this case, the patient presents with persistent and worsening low back pain radiating into the right buttock and left leg to the dorsal foot with numbness. He is status post previous L4-S1 posterior spinal fusion with instrumentation. He has a chronic left foot drop that has worsened with increased giving way, toe catching, and foot slapping. His signs and symptoms are consistent with neurogenic claudication. Clinical examination findings have documented motor deficits, sensory loss, and reflex changes consistent with imaging evidence of adjacent segment disease at L3-4 including disc bulge/extrusion and severe bilateral neuroforaminal narrowing. There is also imaging evidence of potential pseudoarthrosis on the left side, and diffuse idiopathic skeletal hyperostosis. The patient has failed conservative treatment, including physical therapy, home exercise program, water therapy, medications and chiropractic treatment. The proposed surgery is clinically indicated due to the significant adjacent segment disease at L3-4 with the anticipated need for wide decompression. This would result in temporary intraoperative instability and require stabilization at the L3-4 level, and extension of the L4-S1 fusion with instrumentation from L3 to S1. Final Result: The reviewer determined that the requested surgery 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype Dx Breast Recurrence Score testing for evaluation of the enrollees breast cancer. Findings:  Three physician reviewers found that the decision to provide adjuvant chemotherapy is typically based on the pathologic details of an individuals breast cancer. There are specific situations wherein it is not clear whether adjuvant chemotherapy will indeed be beneficial. Amongst such situations are those of this patient, who has a node negative, but estrogen receptor positive, progesterone receptor positive and HER2 negative tumor. Oncotype Dx Breast Recurrence Score testing is a 21-gene assay particularly focused on such patients. The assay will yield a result that not only predicts the risk of recurrence without chemotherapy, but also whether chemotherapy is likely to be effective.  This testing has become a standard of care for patients such as this one.  Final Result: The 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) therapy. Findings:  The physician reviewer found that the submitted documentation and medical literature support the requested services in this clinical setting. TMS is a noninvasive brain stimulating procedure utilized in the treatment of major depressive disorder.  The medical literature supports that TMS tends to be well tolerated with fewer barriers than electroconvulsive therapy, which was reportedly considered in this case.  Further, the American Psychiatric Association (APA) investigated this treatment option and the available literature. The outcome of the investigation in 2010 was an APA endorsement of TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. Prior treatment for this patient have included cognitive behavioral therapy and pharmacotherapy. The standard of care does not require multiple medication trials prior to TMS therapy, which was a rationale for denial asserted by the Health Plan in this case.  The APA endorsement is a compelling determination supporting the use of TMS in this clinical setting. As such, considering the medical records, endorsement from the APA and the expanding peer reviewed literature base, TMS represents a safe and appropriate treatment that is reasonably expected to improve this patients condition and prevent a more serious episode of illness. Therefore, the requested TMS therapy is medically necessary for treatment of the enrollees behavioral health 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 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.