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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Avastin treatment (10 mg injectable every two weeks) for treatment of her cervical cancer. Findings:  Two physician reviewers found that the combination of Afinitor and Avastin is not U.S. Food and Drug Administration (FDA) approved and it is not supported by the medical literature. Moreover, Afinitor and Avastin is not mentioned in the National Comprehensive Cancer Network (NCCN) guidelines as combination or alone. Clinical trials using mTOR inhibitors have largely been with temsirolimus rather than everolimus and have not shown significant response. There are a lack of published trials with the combination of everolimus and Avastin. The use of mTOR inhibitors in combination with other therapies is the subject of several ongoing clinical trials. Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and is 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: 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 his prostate cancer. Findings:  Three physician reviewers found that currently, there is insufficient clinical data to discern whether treatment with proton beam radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer.  Researchers evaluated the comparative effectiveness of intensity modulated radiation therapy (IMRT), proton beam radiation therapy, and conformal radiation therapy for prostate cancer.  In the comparison between IMRT and proton beam radiation therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton beam radiation therapy.  The National Comprehensive Cancer Network guidelines indicate that no clear benefit of proton beam radiation therapy has been demonstrated over standard treatment with photons and IMRT technique.   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: Reviewers 1, 2, and 3 are board certified in radiation oncology and is 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 OxyContin 60 mg, Flexeril 10 mg, Percocet 10/325 and a referral to a spine surgeon for treatment of her back pain. Findings:  The physician reviewer found that the patient has inconsistent urine toxicology testing as well as unauthorized self-escalation of her opiate medications. She has violated the opiate maintenance agreement.  If patients repeatedly fail urine toxicology screening and self-escalate medication, then they are not acceptable candidates for opiate medications. The Centers for Disease Control and Prevention has specifically warned about the dangers of self-escalation and the mortality and morbidity associated with it. Thus, the requested OxyContin 60 mg, Flexeril 10 mg and Percocet 10/325 are not medically necessary for the treatment of this patient.  However, there is sufficient support for the requested referral to a spine surgeon in this clinical setting.  This patient has ongoing pain.  Further surgical evaluation is medically appropriate since she cannot be managed with medications effectively. Final Result: The reviewer determined that a portion of the requested medications and services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa knee injections for treatment of her osteoarthritis of the left knee. Findings:  Two physician reviewers found that intra-articular injections of hyaluronic acid are an established part of treatment algorithms for management of osteoarthritic knee pain and is generally considered a second line treatment after pain medications such as nonsteroidal anti-inflammatory medications. Multiple studies have documented efficacy of intra-articular hyaluronic acid injection for osteoarthritic knee pain. Studies have shown that repeat injection of hyaluronic acid is safe and a multicenter randomized comparative trial determined intra-articular hyaluronic acid injection was safer than standard first line treatment with oral nonsteroidal anti-inflammatory medications. Repeat viscosupplementation is appropriate for this patient who has exhausted other non-surgical treatment options and had excellent relief with prior viscosupplementation in an attempt to avoid total knee arthroplasty. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in orthopedic surgery and is 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 chemotherapy, immunotherapy and a procedure to clear the obstruction in the enrollees bile duct for treatment of the enrollees hepatocellular carcinoma. Findings: The physician reviewer found that this patient has a history of hepatocellular carcinoma.  She has requested coverage for chemotherapy, immunotherapy and a procedure to clear the obstruction in her bile duct.  However, the current medical evidence does not suggest that chemotherapy, immunotherapy, or biliary surgical intervention will reverse the current situation. There is a lack of support for the requested services in this patients case. 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 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: 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 residential treatment center services for treatment of his behavioral health condition. Findings:  The physician reviewer found that residential treatment center services provided were not and are not medically necessary for treatment of the patients behavioral health condition. The patient had no post-acute withdrawals. There was no evidence of suicidality or homicidality, and he was medically and psychiatrically stable. There were no emotional, behavioral, cognitive, or impulsive symptoms that support the medical necessity of residential treatment level of care. He was not manic or psychotic. He was engaged in treatment.  His family has been supportive. The patient did not require the 24-hour a day environment of residential treatment and he could have been stepped down to a lower level of care. 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 psychiatry with sub-specialty certification in addiction 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 reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) treatment for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that according to the documentation submitted for review, the patient had been sober for approximately two months on admission. He reported that he was irritable, anxious, and had insomnia. He had no behavioral, emotional, or cognitive issues, and he was medically and psychiatrically stable. The patient lived with his mother who had opioids in the home for pain management. He required an additional degree of treatment to provide an environment where he could further develop coping skills in setting of living in an environment containing opioids. In addition, he had social anxiety. The patient required PHP treatment to assist him with becoming more comfortable in the group setting which is essential in relapse prevention. He was no longer reserved and he was able to discuss tools to use to remain sober. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 fentanyl transdermal patch 25 mcg/hr for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The records document that the patient is allergic to morphine. Thus, she cannot use that drug as an alternative to fentanyl.  The Health Plan recommended that there be a plan for tapering the opiates.  However, the Centers for Disease Control and Prevention guidelines do not indicate that all patients need to be tapered off opiates.  In this patients case, the treating provider reported that the current regimen of fentanyl 25 mcg/hr and fentanyl 12 mcg/her enables the patient to perform her activities of daily living.  She is stable on this regimen, and there is no evidence of diversion or abuse. 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 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 reimbursement for residential treatment services provided for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the patient was experiencing some physical discomfort on admission. His mental status exam showed loosening of associations and paranoid thinking. He was irritable and agitated, and with the history of bipolar disorder. The night before admission he had threatened violence against his girlfriend and experienced thoughts of self-harm. Although on admission he denied suicidal or homicidal ideation, these are issues which should not be treated lightly especially given his agitated state. On admission he did demonstrate emotional, behavioral, cognitive, and impulsive symptoms that warranted this level of care. He was medically stable but he was not psychiatrically stable. He was significantly calmer and showed no agitation. He was cooperative and participating in the program and groups. He was compliant with taking his Seroquel. There was no evidence of suicidal or homicidal ideation. He could have been stepped down to a lower level of care. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 authorization and coverage for endoluminal ablation of varicose veins. Findings:  The physician reviewers found that the American College of Phlebology Guidelines support the use of endovenous thermal ablation in this clinical setting. There is also a body of evidence that supports the use of endovenous thermal ablation for the treatment of patients with symptomatic incompetence of the accessory great saphenous veins. The standard practice is to treat refluxing accessory (anterior) saphenous veins, which are in communication with the refluxing saphenofemoral junction, with ablation or by phlebectomy, if needed. In this patients case, the severity of her symptoms and the failure of conservative measures to treat her symptoms support treatment with endoluminal ablation. For these reasons, endoluminal ablation of varicose veins are likely to be of greater benefit than other standard modalities for the treatment of this patient. Final Result: 2 of 3 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 vascular 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gene panel testing. Findings:  The physician reviewer found that  There is a lack of clinical data to support the efficacy of the requested services in this clinical setting. Hereditary ataxia (spinocerebellar degeneration) syndromes are in the differential diagnosis of this patients clinical history and findings.  The medical studies do not identify treatment options which are dependent on the results of the proposed genetic testing.  As such, there is a lack of support in the clinical studies to indicate that the requested gene panel testing for this patient would produce health benefits. Therefore, the requested gene panel testing is not likely to be superior to the available standard treatment options for the evaluation of this patients medical condition.Final Result: The reviewers determined that the requested services are 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Hyalgan injection to the left hipfor treatment of the his hip osteoarthritis. Findings:  The physician reviewer found that viscosupplementation is a safe and effective for treatment of pain due to osteoarthritis of the knee and temporomandibular joints. However, viscosupplementation is not U.S. Food and Drug Administration (FDA) approved for osteoarthritis of joints other than the knees and temporomandibular joints. Currently, randomized controlled clinical trials are lacking that address the effectiveness and safety of viscosupplementation of the hip. Preliminary results of small series of patients are encouraging, but further research is needed. Based on the literature and American Association of Orthopaedic Surgeons (AAOS) clinical guidelines, viscosupplementation cannot be recommended as standard treatment in hip osteoarthritis. Final Result: The reviewer determined that the requested service 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H.P. Acthar gel 80 units two (2) times per week for six (6) months for treatment of the enrollees nephrotic range proteinuria associated with membranous nephropathy. Findings: The physician reviewer found that although H.P. Acthar gel could potentially benefit this patient, there is a lack of documentation that the standard of care with an alkylating agent has been exhausted. Based on the current medical literature, treatment with an alkylating agent such as cyclophosphamide is indicated. Since H.P. Acthar gel is not considered a first- or second-line therapy, treatment with an alkylating agent prior to consideration of H.P. Acthar gel is reasonable. 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 nephrology 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 intensive outpatient program (IOP) services for treatment of his behavioral health condition. Findings:  The physician reviewer found that the practice guideline authored by the Department of Veterans Affairs and Department of Defense supports more intensive settings for certain cases stating that There is now a fair amount of research that indicates patients with greater substance use severity and co-occurring problems such as psychiatric disorders and housing problems will do better in more intensive forms of treatment. In this case, the patients substance use disorder was complicated by bipolar illness. The patient was prescribed complex pharmacotherapy with a triad of mood stabilizing medications including olanzapine, lithium and lamotrigine. He was also on gabapentin, which can be helpful for alcohol-related symptoms, and had failed a trial of naltrexone. He was drinking more than two bottles of wine every day while a validated rating scale returned a score consistent with moderately severe depression. Thus, the patients provider recommended IOP treatment. Considering the relevant peer-reviewed literature, current practice guidelines and the clinical documentation submitted for review, the request for IOP level of care is appropriate and reasonably expected to improve the patients condition, bolster relapse prevention efforts and prevent a more serious episode of illness. Final Result: The reviewers 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: Reviewers 1, 2, and 3 are board certified in psychiatry and is 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.