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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton therapy for treatment of the enrollees recurrent left breast cancer. Findings: The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Small studies have demonstrated the ability of proton therapy to reduce lung and cardiac for left-sided breast cancer dose exposure, however it is not clear if such reductions are clinically meaningful for proton therapy to be recommended for general use (MacDonald, et al; Ares, et al). Many other technologies also allow for reduction in normal tissue dosing, including intensity modulated radiation therapy (IMRT). Although the breast is in close proximity to the heart and lungs, it is not evident that proton therapy is needed to sufficiently reduce lung dose-volume exposure in this patients case. The records submitted do not include a dosimetric rationale which demonstrates the insufficiency of three-dimensional (3D) conformal or IMRT. Moreover, proton therapy for breast cancer is not an accepted standard of care. For the reasons provided, the request for proton therapy has not been established as medically necessary for the treatment of the patients breast cancer. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks. 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 (with ribavirin for 16 weeks when NS5A resistance is found) and Epclusa for 12 weeks. The guidelines recommend Epclusa for 12 weeks based on high safety and efficacy in clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) treatment provided from the date of service in question, forward. Findings:  The physician reviewer found that, in the records provided for review, the patients addictive illness has dominated his daily routine for nearly half of his life and contributed to significant impairment across multiple domains of functionality. He has no reliable sober support group. He has a history of impulsive behavior that placed him, and possibly others, at risk of harm. He has co-occurring psychiatric illness and has struggled with self-defeating perfectionism. He has failed multiple chemical dependency treatment programs in the past while the concurrent use of alprazolam and opiates represents a high-lethality combination. The American Society of Addiction Medicine (ASAM) states that the placement decision is the last step in a multidimensional assessment that guides the variety and intensity of services needed in an individualized treatment plan. Further, the American Psychiatric Publishing Textbook of Substance Abuse Treatment reports improved functionality associated with individuals who complete IOP programming. As of the date of service in question, the patient continued to experience anxiety and the sequelae of his characterological organization and addictive illness. He had not yet consolidated the treatment gains necessary to succeed in an outpatient based treatment program. The IOP treatment was and is reasonably expected to improve the patients condition and prevent a more serious episode of illness via relapse, which in-turn would more than likely place the patient and others at risk, and require a more intensive treatment setting. Thus, the services in dispute are safe, appropriate, and consistent with community standards. For these reasons, the IOP services provided from the date of service in question, forward were and are medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were and 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar fusion surgery for treatment of the enrollees back pain. Findings: The physician reviewer found the request for L4-5 lumbar fusion surgery has not been established as medically necessary for treatment of the patients medical condition. The use of posterolateral fusion after failed disc arthroplasty has not been shown to be effective. There is a lack of medical literature supporting posterior-alone revisions of lumbar disc arthroplasty without removing the prosthesis. Alahmadi and Deutsch performed a review of revision surgery for patients with lumbar artificial discs who failed to achieve satisfactory lower back pain control despite the optimal appearance of prosthesis visible on the imaging. The results were not favorable. None of the five patients in the study had significant improvements in their back pain after the fusion. The only patient who had initially significant improvements after the disc replacement, had poor pain control after the fusion. Given the lack of support in the peer-reviewed literature, the requested surgery is not medically necessary for treatment of the 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 neurological 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 authorization and coverage for Otezla 30 mg for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient has failed clobetasol solution, Dovonex ointment and Diprolene for treatment of plaque psoriasis. She has also failed natural sunlight exposure. However, there is no documentation demonstrating that the patient has tried and failed one of the Plans preferred therapies. Given that there is no documented intolerance, contraindication or lack of efficacy to the formulary preferred drugs, the request for coverage of Otezla is not medically necessary for treatment of the patients plaque psoriasis. 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 dermatology 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 lumbar/sacral transforaminal epidural injections for treatment of the enrollees back pain. Findings:  The physician reviewer found that The requested services are medically necessary for treatment of the patients medical condition. The patient has radiating low back pain with a diagnosis of lumbar radiculopathy. She has acute on chronic radicular pain which was rated at greater than 6/10. She had received treatments within the past six months including nearly three months of chiropractic care which included instruction in exercise and rehabilitation. She has imaging findings of multilevel degenerative disc disease with foraminal narrowing and annular tears which supports her radicular complaints. Physical examination findings are consistent with a diagnosis of lumbar radiculopathy. Based on the peer-reviewed literature and clinical documentation, lumbar/sacral transforaminal epidural injections are medically necessary for the treatment of the 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 physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of the enrollees cystic fibrosis and pancreatitis. Findings:  The physician reviewers found that cystic fibrosis is a multisystem disease affecting epithelia of multiple organs including the exocrine pancreas. Given the extreme nature of the patients pancreatic disease, the hereditary pancreatitis panel was used to rule out other potential gene changes in addition to CFTR mutations. Current guidelines recommend sweat chloride testing be done on patients with signs, symptoms or a family history concerning for cystic fibrosis. For patient with sweat chloride testing between 30-59 mmol/L, CFTR mutation testing is recommended. The results of this testing could help determine the patients eligibility for total pancreatectomy with islet autotransplantation (TPIAT). For these reasons, the CFTR portion of the hereditary pancreatitis panel was likely to be more beneficial for evaluation of this patients cystic fibrosis than any available testing, and the remaining portion of the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that a portion of 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 partially overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in pediatrics with sub-specialty certifications in genetics and neurodevelopmental behavioral pediatrics 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 Epclusa for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. 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 with ribavirin for 16 weeks when NS5A resistance is found, Harvoni for 12 weeks, or Epclusa for 12 weeks. In addition, treatment with Zepatier and ribavirin for 16 weeks was demonstrated to be 100% effective despite NS5A resistance in the phase III trial reported by Kwo and colleagues. This patient does not have a definitive medical contraindication to ribavirin, as there is no anemia, and thrombocytopenia was not reported as a side effect of ribavirin in a randomized controlled trial of ribavirin monotherapy. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, although treatment is needed, the request Epclusa for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection as Zepatier is available within the Health Plans formulary. 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a third series of Orthovisc injections for treatment of the enrollees knee pain.Findings:  The physician reviewer found that based upon a review of the literature and guidelines, they do not support viscosupplementation (Orthovisc injections) for more than two series for treatment of osteoarthritis of the knee. While this patient may have responded well to prior series of viscosupplementation injections, the clinical benefit of viscosupplementation for more than two series has not been established in the scientific literature. In addition, multiple repeat series of viscosupplementation is not U.S. Food and Drug Administration approved.  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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for benzphetamine tablets for treatment of the enrollees fatigue. Findings: The physician reviewer found that benzphetamine is approved for management of exogenous obesity as a short-term adjunct (a few weeks) in a regimen of weight reduction based on caloric restriction in patients with an initial body mass index (BMI) of 30 kg/m2 or higher who have not responded to appropriate weight reducing regimen (diet and/or exercise) alone.  In this case, the patient is not using this medication for an FDA approved indication.  His diagnosis includes chronic fatigue syndrome, which is a complicated disease characterized by unexplained, persistent and relapsing fatigue.  The only treatment that has been shown to be effective in treating chronic fatigue syndrome is cognitive behavioral therapy (CBT) and graded exercise therapy. The documentation does not support that the patient has tried and failed non-pharmacologic approaches to chronic fatigue syndrome. For the treatment of ADD, medication with stimulants including dexmethylphenidate, methylphenidate and dextroamphetamine in addition to CBT are considered first-line treatment.  The use of benzphetamine is not supported in this case.  The documentation does not support that he has failed treatment with CBT.  Furthermore, benzphetamine, although a stimulant, is not recommended for treatment of ADD. All told, benzphetamine 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage hip replacement surgery for treatment of the enrollees hip pain and chronic low back pain. Findings: The physician reviewer has found that the documentation provided does not support the medical necessity of the requested services. The American College of Rheumatology 2012 recommended total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. Medical therapy recommendations included exercise, weight loss for overweight patients, medication management, walking aids, and psychosocial interventions. Liu and colleagues stated that their meta-analysis of prospective cohort studies demonstrated that obesity negatively influences the overall complication rate, dislocation rate, functional outcome and operative time of primary total hip arthroplasty. She has reported significant functional limitations in weight bearing activities. Clinical examination findings are consistent with imaging evidence of end-stage osteoarthritis of the right hip. Reasonable and/or comprehensive nonoperative treatment has been tried and has failed to provide sustained relief. However, she has an elevated BMI and significant comorbidities, including diabetes, which would place her at an elevated risk of postoperative complications based on current medical guidelines and literature. Instead, the treating provider has recommended postponement of total hip replacement surgery until the patient is optimized with a BMI of 35 or less. Therefore, the hip replacement surgery is not medically necessary at this time. Final Result: The reviewer determined that the requested procedure 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for parathyroid planar imaging single-photon emission computed tomography/computed tomography fusion imaging for evaluation of the enrollees hypercalcemia and elevated parathyroid hormone levels.Findings: All three physician reviewers found that this patient presents with classic laboratory evidence of primary hyperparathyroidism.  While laboratory values can be transiently or inaccurately high on occasion, there have been repeated assays, and the laboratory findings appear to be legitimate and reproducible.  Primary hyperparathyroidism is usually caused by a solitary benign adenoma (80 to 85 percent), but can also be due to double adenomata (2 to 5 percent), diffuse or nodular hyperplasia (10 to 15 percent), or parathyroid carcinoma (less than 1 percent). In the past, the next step would have been to perform a full exploration of the neck and to interrogate all four parathyroid glands.  Currently, a more focused, minimally invasive approach to parathyroid surgery is being adopted at many centers.  The goal has been to localize the suspected tumor prior to surgery.  Typically, a sonogram of the neck is performed, but it is generally difficult to distinguish a thyroid nodule from a parathyroid nodule.  A routine enhanced computed tomography (CT) scan is often insufficient, as these nodules are generally small, and are again masked by the thyroid gland which may, in itself, have intrinsic nodules. Over the years, nuclear medicine has become the standard means to diagnose a parathyroid nodule.  However, there are still limitations to a routine sestamibi technetium parathyroid scan, mainly related to the potentially small size of the adenoma.  In recent years, SPECT/CT scans have become the state of the art.  By fusing the nuclear medicine SPECT scans with the CT images, one can best localize the offending adenoma, and provide guidance for the minimally invasive surgery.  Per the medical evidence, the requested services are likely to be superior over other methods of evaluating this patient.Final Result: All three 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.