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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for proton beam radiation therapy. The enrollee has a history of recurrent sarcoma of the thigh. The enrollees radiation oncologist reports the enrollee has experienced multiple, recurrent, high-grade, undifferentiated spindle cell sarcomas of his left thigh. He had a surgical resection, followed by conventional photon radiation therapy. Four years later, he required a re-excision for local recurrence. He recently developed a biopsy-proven recurrence in his left thigh within the area of the previous radiation portal. He was initially treated with chemotherapy. His disease continued to progress. His provider believes the use of proton beam therapy in these circumstances is needed because it is the most advanced form of proton therapy. It allows physicians to precisely paint the tumor with radiation, minimizing radiation exposure to healthy tissue and reducing the risk of side effects. Literature describes protons as particularly useful in bone tumors, pediatric sarcomas, and spinal lesions, due to the ability to restrict the dose to critical anatomical structures or vulnerable developing tissues. Studies show the use of high-dose photon/proton radiotherapy resulted in local control rates in the management of non-spine (long bone) sarcomas of 81 percent at five years and 74 percent at eight years. This enrollee cannot be effectively treated with photons alone in this clinical situation. Professional society guidelines do allow the use of proton therapy for this extensive recurrent sarcoma.Final Result: Three of the three reviewers determined that the requested services were likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in radiation oncology and are actively practicing.  All three 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: The patient has requested authorization and coverage for bariatric surgery consultation. The records provided for review document that this patient is morbidly obese. The patient may benefit from bariatric surgery. As noted, Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. As a team approach to perioperative care is essential, the authors noted that the determination for surgical intervention should be evidence-based within the context of a chronic disease. For this patient, a consultation with a bariatric surgeon would determine whether he is a candidate for bariatric surgery and whether he meets the requirements for surgical intervention. All told, the bariatric surgery consultation is medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 surgery with expertise in bariatric 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

The enrollee is requesting authorization and coverage for Humira CF pen, 40mg/0.4ml subcutaneous every other week. The enrollee has arthropathic psoriasis. The enrollee complains of pain in the sacroiliac joints and left index finger. She also reports burning in her right finger and now has a subcutaneous nodule over the proximal tendon on the palm. The enrollee has tried Vimovo, but it resulted in gastrointestinal upset. She has also tried and failed meloxicam. The provider reports the enrollee is refraining from methotrexate because the enrollees current use of Valtrex could raise concerns for kidney damage. Non-biologic disease-modifying anti-rheumatic drugs, such as methotrexate and sulfasalazine, are used primarily for peripheral psoriatic arthritis. In this enrollee, seronegative spondyloarthropathy is the bigger problem, for which tumor necrosis factor inhibitors are the preferred treatment. A professional society reports Sulfasalazine or methotrexate should be considered only in those with prominent peripheral arthritis or when tumor necrosis factor inhibitors are not available. The guidelines indicate non-steroidal anti-inflammatory drugs and tumor necrosis factor inhibitors remain the primary classes of medications for the treatment of spondyloarthritis. Literature shows tumor necrosis factor inhibitor therapy can be used when individuals have failed non-steroidal anti-inflammatory drugs, as is the case for this patient.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurology 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the breast. The medical records document that this patient has a BRCA positive test results. Based on current guidelines from the National Comprehensive Cancer Network (NCCN), an annual MRI screening with contrast is recommended for further evaluation of patients with BRCA mutations. MRI with contrast is the most sensitive noninvasive screening method for detection of breast cancer in high-risk female patients and has been validated for those with BRCA mutations. Bilateral breast MRI with contrast has been established as the standard of care as the recommended screening method for breast cancer detection for women with BRCA mutations. For these reasons, the requested MRI of the breast is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested MRI of the breast is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty 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: Overturned Decision of Health Plan

An enrollees parent has requested authorization and coverage for Aimovig. A recent presentation at the American Headache Society (AHS) discussed patients with migraine on Botox who experience end of treatment cycle wear down. The AHS noted that the addition of Aimovig boosted Botox efficacy and resulted in sustained effects in a significant proportion of patients. Combination therapy with Botox plus Aimovig utilizes different mechanisms of action, with a synergistic benefit. Although the available data are on this combination therapy is limited, the published evidence is supportive of its safety and efficacy. This patient has failed multiple standard therapies and has a contraindication to treatment with beta-blockers, selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants. Given the support in the medical literature, Aimovig is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found that the requested Aimovig is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is 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 1, 2, and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for H.P. Acthar gel injections. The enrollee has multiple sclerosis. The medical records report the enrollee has experienced severe acute, debilitating exacerbations of this disease, negatively impacting his physical and mental health and quality of life. The enrollee has experienced worsening fatigue, heat intolerance, decreased range of motion in the right foot, decreased tone of the right lower extremities, and diminished deep sensation in the right upper extremities. He has failed to respond to conventional therapies, including Tysabri, Avonex, and dalfampridine. The enrollee has a contraindication for corticosteroids. Research shows adrenocorticotropic hormone has additional immunomodulatory benefits, apart from its stimulation of endogenous corticosteroid release.  A researcher reports there is renewed and appropriate interest in using this decades-old therapy for multiple sclerosis and other inflammatory disorders.  Adrenocorticotropic hormone remains Food and Drug Administration-approved for multiple sclerosis exacerbations; new studies indicate possible additional benefits over corticosteroids.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Synvisc-One injections for both knees. The enrollee has primary osteoarthritis of both knees. She had cortisone injections to the left knee, with reported benefit duration of about two weeks. The enrollee received cortisone injections to her bilateral knees due to intense pain. The enrollee reported significant pain relief from Synvisc-One injections. She contacted the provider one month later with complaints of throbbing in both knees and requested another cortisone injection. The provider advised the enrollee that she needs to wait at least three months between cortisone injections. The enrollee was prescribed voltaren gel. A professional societys guidelines indicate intra-articular hyaluronic acid injections (Synvisc) have been suggested as a treatment for those with symptomatic osteoarthritis of the knee who have failed all other treatments. The requested intra-articular hyaluronic acid injections (Synvisc) are indicated for those who have knee arthritis with clinical symptoms of crepitus and pain. The enrollee has trialed conservative treatment and an invasive course without resolution of symptoms. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Grastek tablets. This patient has evidence of allergic asthma that has required treatment with medium dose corticosteroids. He has experienced significant asthma exacerbations. He has positive skin testing for pollens and dust mites. There is evidence that patients with allergic asthma benefit from allergen immunotherapy with improvement in asthma symptoms as well as progression of asthma with age. Treatment with Grastek has the potential to decrease this patients inhaled corticosteroid requirement. For these reasons, the requested Grastek is medically necessary for treatment of this patient. 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 subspecialty certification in allergy and immunology 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

The patient has requested authorization and coverage for Matrix Autologous Chondrocyte Implantation (MACI). The U.S. Food and Drug Administration (FDA) indications for MACI states that this autologous cellular scaffold product is indicated for the repair of single or multiple symptomatic full thickness cartilage defects of the knee with or without bone involvement. Researchers found that MACI is an effective and durable treatment for full thickness cartilage defects in the knee. The authors reported that MACI provides satisfactory results in terms of pain relief and knee function rehabilitation, which appear to be sustained in the majority of patients according to long-term follow-up results. Researchers concluded that MACI demonstrated successful outcomes in 82% of patients over the long-term. However, increased patient age and lesion size greater than 4.5 x 4.5 cm were risk factors for a higher reoperation and failure rate. This patient presents with a five-month history of persistent left knee pain and occasional catching. The patient has documented functional limitations with activities of daily living. She is status post left knee arthroscopy with chondroplasty. Operative findings included a 1.5 x 1.5 cm full thickness chondral defect on the lateral femoral condyle. The patient has failed to improve despite reasonable and comprehensive conservative treatment. Current evidence-based medical literature supports the use of MACI as safe and effective with better long-term outcomes as compared to microfracture surgery in this clinical setting. Given these findings, the requested MACI is medically necessary for treatment of this patient.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for Psychiatric Intensive Outpatient Program (IOP) services.In this case, in terms of risk of harm, the records support a score of 3, which corresponds with a significant risk of harm. This is due to the patient's impulsivity, destruction of property, aggression, and recent substance abuse. With regards to functional status, the records support a score of 3, which reflects moderate functional impairment, due to the patients conflict with his mother, his defiant behavior with IOP staff, as well as his maintenance of abstinence from substances while enrolled in the IOP program. In terms of comorbidity, the records support a score of 3. With regards to the level of stress of the recovery environment, the records support a score of 3 In terms of the level of support of the recovery environment, the records support a score of 2, as the patients mother actively participated in treatment, thereby providing a supportive environment. With regards to resiliency and treatment history, the records support a score of 4, which reflects poor resiliency and response to treatment. In terms of acceptance and engagement of the patient, the records support a score of 3. Thus, the patient had a composite score of 21. Using the CALOCUS level of care determination decision tree, the recommended level of care is Level Four: Medically Monitored Community-Based Services. As the current program offers wrap-around services, including 24-hour crisis support, it is consistent with this level of care. Therefore, the Psychiatric Intensive Outpatient Program (IOP) services at issue and going forward were and are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services 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, with subspecialty certification in child and adolescent 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

An enrollee has requested reimbursement for urinary tumor marker testing (Cxbladder Detect Test). Molecular testing for the detection of bladder cancer remains an adjunct to standard evaluation, which includes cystoscopy, urine cytology, and possible imaging. Urinary biomarkers including the Cxbladder Detect may be useful in increasing the sensitivity of diagnosis, which might reduce the need for frequent imaging with computed tomography (CT) and endoscopy. However, urine messenger RNA testing to detect gene expression for bladder cancer cells has not been demonstrated in large randomized controlled clinical trials to improve patient health outcomes when compared with the current standard of care. The recommended course of action for patients with microhematuria continues to be contrast enhanced imaging of the urinary tract and cystoscopy. This patients records demonstrate the presence of microhematuria. However, a renal ultrasound in revealed normal findings. All told, the urinary tumor marker testing (Cxbladder Detect Test) was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the urinary tumor marker testing (Cxbladder Detect Test) was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient reported continued use without any period of sobriety longer than one week. The patient placed himself and others at risk due to his driving while intoxicated. The patient has a history of HIV and chronic lumbar back pain with sciatica. The patients emotional conditions include a diagnosis of major depressive disorder. The provider reported that the patient was in the contemplation stage of recovery as evidenced by his ambivalence and discomfort about participating in Alcoholics Anonymous. The patient was at continued risk of relapse, as he reported cravings of 5/10 and he lacked distress tolerance skills, impulse control, and insight. The patients recovery environment did not include a sober support network. The patient required a safe and stable living environment in order to develop his recovery skills. He qualified for ASAM Level III treatment, similar to what patient received at the RTC facility. Given the severity of the patients illness, the RTC services were medically necessary for treatment of this patient.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 with expertise 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