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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for proton beam therapy for treatment of the enrollees recurrent astrocytoma. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested service. There is a lack of peer-reviewed literature supporting proton therapy as superior to photon therapy to health outcomes for astrocytoma. The National Comprehensive Cancer Network (NCCN) guidelines do not address proton therapy for gliomas, either as salvage therapy or upfront therapy. The documentation submitted for review lacks a dosimetric rationale for the need of proton therapy for this patient. Reirradiation with intensity-modulated ration therapy (IMRT) or other photon based techniques with cumulative doses of 100+ Gy are generally tolerated. In addition, the medical records do not adequately document that an IMRT plan would be unacceptable using quantifiable dosimetric measures. In the absence of dosimetric evidence supporting proton beam therapy, the request for proton beam therapy has not been established as medically necessary for the treatment of the patients medical condition.  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 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 reimbursement for transcranial magnetic stimulation (TMS) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation and medical literature support the services at issue 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. 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. In this particular case, the patients affective illness was not disputed. The patient had pursued, but not exhausted, other standard therapies used to combat depression. Thus, common alternatives may have also been considered medically necessary as defined by the Health Plan. However, considering the medical records, endorsement from the APA and the expanding peer reviewed literature base, TMS represented a safe and appropriate treatment consistent with standard medical practice. TMS was reasonably expected to improve the patients condition and prevent a more serious episode of illness at the time of service delivery.  As such, TMS received was medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cryosurgical ablation for evaluation of the enrollee who has been diagnosed with ovarian cancer. Findings:  2/3 of the physician reviewers found that the standard therapy for metastatic disease in ovarian cancer is systemic therapy, primarily chemotherapy and/or hormonal therapy. This patient with a cardiophrenic lymph node metastasis is asymptomatic and does not necessitate localized therapy since this treatment modality has not been shown in randomized clinical trials to provide a survival benefit over systemic therapy or observation. Cryotherapy, as used in this patient, was not medically indicated since this patient is asymptomatic and systemic therapy is considered the standard. The standard and the most widely used and accepted approach is external beam radiation. Cryotherapy has not been proven as an advantage over radiation therapy. Accordingly, in this patients case, cryosurgical ablation provided was not likely to have been superior over the standard modalities for the treatment of this patients medical condition. Final Result: 2/3 of the reviewers determined that the services at issue were 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 diagnostic radiology with sub-specialty certification in interventional radiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bronchial thermoplasty for treatment of the enrollee who has a history of uncontrolled asthma. Findings:  The physician reviewers found that The Food and Drug Administration (FDA) has approved bronchial thermoplasty for the treatment of adults 18 years or older who are diagnosed with severe asthma that is not well controlled with inhaled glucocorticoids and long acting beta agonists. Bronchial thermoplasty refers to a technique of applying heat to the airways during bronchoscopy and reduces the increased mass of airway smooth muscle associated with asthma. The medical studies have shown a significant improvement in patients who underwent bronchial thermoplasty. In a follow up of 162 patients who underwent bronchial thermoplasty in the AIR2 trial, the proportions of subjects experiencing exacerbations or emergency department visits in years one to five were lower by 44 and 78 percent, respectively, compared with the year before bronchial thermoplasty. Based on the submitted clinical information supported by progress notes and pulmonary function testing, this patient met the criteria for coverage for bronchial thermoplasty.  The clinical information shows evidence such as the need for intermittent/continuous oral glucocorticoids and maximal inhaled corticosteroid treatment. Therefore, bronchial thermoplasty was likely to have been more beneficial for the treatment of this patients medical condition than the available standard methods. Final Result: Two of three reviewers determined that the services at issue were 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:  Physician reviewers number one, two, and three are board certified in allergy and immunology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that The physician reviewer found 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. For these reasons, Zepatier 50-100 mg for 12 weeks is medically necessary for the treatment of this patient. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing for evaluation of the enrollees malignant melanoma. Findings:  The 3 physician reviewers found that the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Gene Assay has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is a lack of published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was 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 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.Physician reviewer number two 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.Physician reviewer number three 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: The patient has requested authorization and coverage for knee arthroscopy and surgery room services for treatment of the enrollees tear of anterior cruciate ligament (ACL) of left knee and sprain of medial collateral ligament of left knee. Findings:  The physician reviewer found that : Based on the medical literature and this patients assessment following exhaustion of conservative therapies, the requested arthroscopically assisted anterior cruciate ligament (ACL) repair and arthroscopic assessment and repair of any additional intraarticular pathology found at surgery is supported as medically necessary for treatment of this patients medical condition. The treatment plan includes arthroscopically assisted allograft bone tendon bone reconstruction. The current data suggests that unrepaired ACL conditions can lead to ongoing instability and an accelerated failure of cartilage surfacing with early development of degenerative osteoarthritis. Cartilage surfacing of the joint is generally strong in compression in a stable knee but weak in an unstable knee. The planned surgery for this patient is consistent with those principals. Thus, the requested knee arthroscopy and surgery room services is supported as medically necessary for treatment of this 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the occipital nerve block injections for treatment of the enrollees occipital neuralgia. Findings:  The physician reviewer found that The documentation submitted for review demonstrates the presence of occipital neuralgia as documented by physical examination findings. However, occipital nerve blocks are not supported for the treatment of migraine or other type headaches. Occipital nerve block are supported for diagnostic purposes, and not for therapeutic treatment as there is no long-term benefit supported in the peer-reviewed literature. There was no long-term improvement of headache of chronic migraine type with use of occipital nerve block. Greater occipital nerve block does not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Nno long-term improvement of headache of chronic migraine type with use of occipital nerve block. As such, the occipital nerve block injections provided were not likely to be more beneficial for treatment of the patients occipital neuralgia than any available standard therapy. Final Result: Two of three reviewers determined that the service at issue was not likely to be more beneficial for treatment of your medical condition than any available standard therapy. Credentials/Qualifications:  Physician reviewera number one, two ,and three are board certified in neurology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for stereotactic body radiotherapy for treatment of the enrollees prostate cancer. Findings:  The physician reviewer found that The physician reviewer found the medical evidence has not established the superior effectiveness of stereotactic body radiotherapy in this clinical setting. Outcome data for stereotactic body radiotherapy at this time is limited to five-year to six-year follow-up. The study by Katz and colleagues evaluated prostate cancer patients treated with stereotactic body radiotherapy (total patient number was 304, and 81 were intermediate-risk). The five-year biochemical disease free survival was 90.7% for intermediate-risk, and toxicity was also acceptable.  Overall, these outcome data appear similar to conventionally fractionated radiotherapy, but do not demonstrate that stereotactic body radiotherapy is likely to be more beneficial. Additionally, longer follow-up would be optimal due to the long natural history of prostate cancer.  In sum, stereotactic body radiotherapy was not likely to have been of greater benefit than conventionally fractionated intensity modulated radiation therapy. Final Result: The reviewers determined that the services at issue were 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: The patient has requested authorization and coverage for services with an immunologist/allergist within five miles of the enrollees residence for treatment of the enrollees persistent respiratory disease and multiple chemical sensitivity. Findings:  The physician reviewer found this is a case of a patient with multiple chemical sensitivity (MCS), chronic rhinosinusitis, chronic cough, common variable immune deficiency (CVID), and severe reactive bronchospasm. The records contain a diagnosis of severe hyper-reactivity but fail to provide supporting documentation such as pre- and post-pulmonary function tests (PFTs), emergency department visits, clinical findings of asthma, and bronchodilator use. In addition, vasomotor rhinitis and cough are noted as symptoms but further description of flare is not provided in the documentation. According to the American College of Occupational and Environmental Medicine (ACOEM), therapy is to be individualized to the patient in the clinical setting of idiopathic environmental intolerance (IEI). Focus continues to be on a patients triggers and ameliorating factors, while avoidance continues to be the best treatment strategy. The ACOEM guideline states that, there are no proven or effective treatments for IEI. Although it is not clear whether psychologic symptoms are the cause of IEI or whether they merely accompany the diagnosis, cognitive and behavioral interventions such as relaxation techniques, breath-control exercises, and a structured plan to increase overall physical and social activity (lifestyle changes) may be useful in the treatment of IEI. The records fail to demonstrate that she is home bound or otherwise limited. Overall, the medical records fail to demonstrate clinical findings supporting the medical necessity of an immunologist/allergist within five miles of the patients residence. Final Result: The reviewer determined that the 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 certifications in allergy and immunology and rheumatology 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 Epclusa for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 3a. Findings:  The physician reviewer found that According to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, although this patient discontinued Sovaldi and ribavirin due to adverse effects, Epclusa for 12 weeks is also appropriate for non-cirrhotic patients who have failed Sovaldi and ribavirin, based on near-complete cure rates in this group in the POLARIS-4 trial. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Epclusa for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.