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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen therapy for treatment of the enrollees sudden idiopathic sensorineural hearing loss. Three physician reviewers found the submitted documentation fails to demonstrate the superior effectiveness of the requested services in this patients case. Multiple articles suggest some modest improvement in hearing with the use of hyperbaric oxygen therapy. Most of these articles state that the effect is greater in patients with a modest degree of hearing loss when the therapy is administered early in the treatment protocol after the traditional use of oral and intratympanic steroids. Bennett and colleagues noted that for people with acute sudden sensorineural hearing loss, the application of hyperbaric oxygen therapy significantly improved hearing, but the clinical significance remains unclear. There is the risk of serious side effects with hyperbaric oxygen therapy. Per the medical evidence, potential risks include damage to ears, sinuses, and lungs from pressure changes, claustrophobia, and oxygen poisoning. At this time, the medical evidence has not established that hyperbaric oxygen therapy is likely to be of greater benefit than other available treatment options. Final Result: The 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: Physician reviewer number one is board certified in otolaryngology 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.Physician reviewer number two is board certified in otolaryngology 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.Physician reviewer number three is board certified in otolaryngology 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 DecisionDx-Melanoma testing for evaluation of the enrollees melanoma. Findings:  The physician reviewer found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing was not likely to have been superior over other available modalities for evaluating this patient. Fulfills 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical 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: An enrollee has requested authorization and coverage for proton beam radiation therapy for treatment of the enrollees Stage IIA invasive ductal carcinoma.  Findings:  All three physician reviewers found that the request for proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of peer-reviewed literature demonstrating that proton therapy affords a benefit over other standard available therapies such as photon therapy for breast cancer. While proton therapy will almost always appear superior to photon therapy dosimetrically due to its Bragg peak, this does not necessarily translate into a clinical benefit. The uncertainty of proton therapy is reflected in a recently trial designed specifically to look at cardiac toxicity for photons versus protons, including dose-volume analysis of cardiac substructures. For the reasons provided, proton beam radiation therapy is not 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 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three is board certified in radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mohs surgeryfor treatment of the enrollees squamous cell carcinoma in situ (SCCIS). Fulfills Findings:  The physician reviewer found that the requested surgery is not medically necessary for treatment of the patients medical condition. According to the American Academy of Dermatology appropriate use criteria for treatment of non-melanoma skin cancers, Mohs surgery is indicated for certain areas of the face, for tumors which are a large size or found to have an aggressive growth pattern by pathology. In this case, the squamous cell carcinoma in situ does not meet those criteria. Standard excision or topical therapies is the standard of care for definitive therapy in this clinical setting. Therefore, Mohs surgery is not medically necessary for treatment of this patient.  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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center for treatment of the enrollees behavioral health condition. Fulfills requirements of (1374.33) Findings:  The physician reviewer found that Based on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is two (2), low risk of harm. The patient has no prior suicide attempts. The patient did not have any suicidal or homicidal ideation.  The patients functional status score is three (3), moderate impairment. The patient had a significant deterioration in his ability to fulfill responsibilities and obligations. The patients medical, addictive and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of alcohol use disorder, opiate use disorder, sedative hypnotic use disorder, and PTSD. The patient has no medical problems that would require 24-hour observation. The patients recovery environment score is two (2), mildly stressful environment. The patients spouse is supportive. The patients level of support score is two (2), supportive environment. The patient has a supportive spouse. The patients treatment history score is three (3), equivocal response to treatment and recovery. Previous treatment for substance use has been equivocal. The patient has continued to struggle with sobriety. The patient has a history of attending Alcoholic Anonymous (AA) meetings. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient is cooperative and compliant with treatment. The patient is highly motivated for sobriety. The patient participated in groups and activities. Based on these criteria, the patient has a total score of 17 and would meet criteria for an intensive outpatient program. The patient could have been provided in a less restrictive environment. Therefore, RTC level of care services provided were not medically necessary for treatment of the patients medical condition. 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of direct applied behavioral analysis (ABA) therapy for treatment of the autism spectrum disorder.  Findings:  The physician reviewer found that the documentation submitted for review does not support the medical necessity for 30 hours per week of direct ABA therapy. The 20 hours per week of ABA therapy authorized by the Health Plan is medically reasonable for this patient. According to the documentation submitted for review, the patient is making progress with ABA therapy, and there does not appear to be a medical indication for 20 hours per week of direct ABA per week. The patient is documented have had stable or improved performance across all areas. The patient is becoming increasingly more open and responsive to his treatment, and he is learning to take more responsibility for the patients actions and behaviors. Based on the clinical documentation submitted for review the services at issue were not and are not medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 automated insulin delivery for treatment of the enrollees diabetes type I. Fulfills Findings:  The physician reviewer found that The requested device is considered investigational as long term studies are not available. There is not enough long term data to show that it is superior over other monitoring devices. At this time, the incremental benefit of automated closed loop control of insulin administration is unclear. There is currently no 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 CGM. However, due to the non-randomized study, design and lack of a control arm, statements pertaining to its efficacy are limited. Therefore, the requested automated insulin delivery device is not likely to be more beneficial than the standard options for managing this patients blood glucose levels. Final Result: Two out of three 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 amlodipine-olmesartan 5 milligrams - 20 milligrams, taken once a day for treatment of the enrollee who has a history of hyperlipidemia, hypertension and chronic kidney disease. Findings:  The physician reviewer found that The documentation provided does not support the medical necessity of the medication  at issue. Based on the records provided the patient has been diagnosed with chronic kidney disease. There is no documented medication intolerance or allergies to amlodipine-olmesartan. The records also indicate that the patients hypertension is controlled on amlodipine-olmesartan. However, in this patients case there are several preferred formulary alternative medications that are in the same class as amlodipine-olmesartan. The medical literature shows that the formulary alternative medications are equally effective in managing blood pressure. Moreover, there is some evidence that these formulatry alternative medications are equally effective in preventing progression of chronic kidney disease. There is no documented trial or intolerance to any of these preferred formulary alternatives and there is no unique benefit of amlodipine-olmesartan over other medications in the same class that would make continued treatment with Azor medically necessary. Current guidelines for the treatment of hypertension are also in support of benefit based on medication classes without unique benefit of one medication over another within the same class. Therefore based on the records provided, amlodipine-olmesartan 5 mg - 20 mg, taken once a day was not and is not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the medication at issue was not and is not medically necessary for evaluation 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 cardiovascular disease 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 a consultation with an orthopedic surgeon for evaluation of the enrollees low back pain. Findings:  The physician reviewer found that in the medical literature, Tosteson and colleagues compared the effectiveness of surgery over non-operative treatment for four years in patients with similar conditions. The authors found that comparative effectiveness evidence for clearly defined diagnostic groups from Spine Patient Outcomes Research Trial shows good value for surgery compared with non-operative care over four years. Baranowska and colleagues reported on 601 patients with degenerative disc disease who underwent surgery, of whom 107 patients had previously undergone surgery. The authors noted that most frequent reasons for revision surgery of the same motor segment were recurrent disc herniation, inadequate decompression and inappropriate surgical technique. This patient has evidence of failed back surgery with low back and radicular leg pain. An orthopedic referral is medically necessary to evaluate her persisting pain and to manage it appropriately. As such, the request for an orthopedic referral is medically necessary for evaluation and management of the patients medical condition.  Final Result: The reviewer determined that the requested referral is medically necessary for evaluation 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for surgery to install a plate to stabilize a broken collarbone for treatment of the enrollees fractured collarbone.Findings:  The physician reviewer found that the in this patients case, evidence based medical peer reviewed literature supports open reduction and plate fixation of acute displaced mid-shaft clavicular fracture as safe and effective. The risk of non-union is significantly lower after operative treatment than after non-operative treatment. This patient sustained a complex right clavicular fracture. X-rays showed a comminuted displaced fracture in the mid-clavicle with inferior displacement. The initial orthopedic provider discussed surgical and non-surgical options and indicated that the patient chose non-surgical treatment. Over the next two days, the patient reported significant pain with instability and desired surgical fixation of the clavicle fracture. There is current evidence based medical literature to support open reduction and plate fixation of this fracture to lower the risk of non-union. According to the documentation provided, this patient meets the surgical criteria for plate fixation given the complex right clavicular fracture and symptoms reported. Therefore, surgery to install a plate to stabilize the patients broken collarbone is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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.