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

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for the laboratory services. Lactulose is a non-absorbable substance that is metabolized by gut bacteria in the colon with the production of hydrogen and/or methane. In patients without SIBO, the administration of lactulose results in a single peak in breath hydrogen or methane within two to three hours due to the metabolism of lactulose by colonic flora. In patients with SIBO, administration of lactulose results in an early peak in breath hydrogen or methane levels due to metabolism by small bowel bacteria. Given the current support in the peer-reviewed medical literature, the testing was appropriate in this clinical setting. Thus, the laboratory services were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the laboratory services were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral incisionless fundoplication (TIF) procedure. TIF is an endoscopic procedure performed to create a full-thickness serosa-to-serosa plication. TIF can be performed in patients with typical GERD symptoms, no or low-grade erosive esophagitis, and either no hernia or a small hiatal hernia measuring less than 2 cm. This patient meets these criteria. However, the durability of TIF is less certain than that of standard available interventions. In a meta-analysis of five randomized trials and 13 prospective studies, proton pump inhibitor use after TIF increased over time. This patient has reported 80% symptom relief with use of Dexilant. Thus, the records do not demonstrate that the TIP procedure is likely to provide greater benefit than standard available therapies. Accordingly, the requested TIF with the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested TIF with the EsophyX device is not 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 TIF with the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: An enrollee requested reimbursement for residential treatment services provided. The diagnoses include Major Depressive Disorder, Anxiety, Oppositional Defiant Disorder (ODD), and Obsessive Compulsive Disorder (OCD). The medical records reviewed indicated self-reports of improving mood; however, mental examination documented minimizing situations, tearfulness, and a safe discharge had not been in place. The APA Guidelines for major depressive disorder (MDD) notes the determination of an appropriate setting for treatment should include consideration of the patients symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning. Determination of a treatment setting should also include consideration of the patients ability to adequately care for him- or herself, to provide reliable feedback to the psychiatrist, and to cooperate with treatment of the major depressive disorder. Measures such as hospitalization should be considered for patients who pose a serious threat of harm to themselves or others.In this case, the patients severity of illness and serious risk of self-harm is demonstrated by her severe depression. Regarding a support system, she has only limited support from a roommate and expressed concern about isolation at home. APA criteria for RTC level of care have been met. Therefore, the RTC services provided were medically necessary for this patient.Final Result: The reviewer determined that the requested services was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg tablets, 60 tablets for 30 days. The submitted documentation supports the medical necessity of the requested medication. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-tumor necrosis factor drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. It has been well-documented that therapies of psoriasis with injectable biologics increase the risk for malignancy and infection, mandating prior testing for tuberculosis. Apremilast (brand name Otezla), an oral PDE4 inhibitor, provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Its effects on cyclic adenosine monophosphateregulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. In this case, the patient has chronic plaque psoriasis that requires systemic treatment. The immunosuppressant and anti-tumor necrosis factor drugs recommended by the Health Plan can increase the risk for infection and malignancy. The medical evidence supports Otezla in this clinical setting. Therefore, Otezla 30mg, 60 tablets for 30 days, is medically necessary for treatment of the patients medical condition.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 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: At issue in this case is whether the requested selective internal radiotherapy (SIRT) using Y-90 (CPT 37423) is medically necessary for treatment of the patients medical condition. This is a 64-year-old male who was diagnosed in 2015 with colon cancer and underwent surgery. He was staged as a T3N0M0. He did not receive adjuvant chemotherapy. In 2018 he was noted to have increasing abdominal pain. He was found to have an 8.3 cm mass in the right lobe of the liver. No disease was noted in the chest. His biopsy revealed a necrotic neoplasm. He was started on chemotherapy which he tolerated with no major complications. His repeat CT has shown no interval improvement in the size of the mass, and he is deemed inoperable.Findings:  The physician reviewer found that Patients with colon cancer that has spread to the liver are candidates for radioembolization (also known as SIRT) which has been shown to improve outcomes in this setting. The evidence suggests that radioembolization may be associated with a greater response which may facilitate eventual surgical resection (Shamimi-Noori et al and Fairchild et ano). National Comprehensive Cancer Network guidelines endorse the use of radioembolization therapy in this setting. The medical records indicate the patient has no contra-indication to receiving this therapy. Therefore, selective internal radiotherapy (SIRT) using Y-90 is medically necessary..Final Result: requested treatment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: I am board certified in radiation oncology and I am actively practicing. I am 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: enrollee has requested reimbursement for DecisionDx-UM testing.Findings:  Three physician reviewers found that local treatment for primary uveal melanoma is effective in preventing local recurrence in over 95 percent of cases, yet up to 50 percent of patients are at risk for metastatic disease. The high risk of metastatic disease is thought to be due to a propensity for early micrometastasis followed by a variable latency period prior to the emergence of overt metastatic disease. Gene expression profiling has been shown to be superior to chromosomal markers, as well as clinical and histopathological prognostic factors, for defining groups at high risk for the development of metastatic disease. Using primary uveal melanoma samples obtained by fine needle biopsy, gene expression profiling classifies tumors as having low (class 1) or high (class 2) metastatic potential. The risk of metastasis guides surveillance. DecisionDx-UM testing is considered a standard of care in this clinical setting. In sum, DecisionDx-UM testing was likely to have been more efficacious than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 residential treatment center services. Diagnoses include bipolar disorder, depression, and substance abuse. He presented for admission to residential treatment complaining of depression and reporting homelessness. At admission, he denied suicidal or homicidal ideation, and although agitated, there was no evidence of a desire to be aggressive or violent towards others. He was capable of caring for himself and performing all activities of daily living. He demonstrated capability and willingness to participate in treatment. There are no other emotional, behavioral, or cognitive factors requiring 24/7 nursing and medical monitoring. He was medically and psychiatrically stable to the point that he did not require this type of structured setting, the medication management was of an outpatient nature. The medication noncompliance issues could have been dealt with on an ambulatory level of care as they were chronic in nature and were not acutely life threatening. Lack of social support does not require residential level of care. 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 geriatric 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (cell-free fetal DNA-based prenatal screening).Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this patients case. Noninvasive prenatal screening by cell-free DNA is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is more sensitive than sequential screening and does not require the invasive procedure of chorionic villus sampling or amniocentesis. Therefore, genetic testing (cell-free fetal DNA-based prenatal screening) performed was likely to have been more efficacious than other methods of evaluating this patient.   Final Result: The reviewers determined that the services at issue were 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 clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in clinical genetics and genomics 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: A review of the record indicates that the enrollee has been diagnosed with chronic pain syndrome, generalized joint pain and acute hematogenous osteomyelitis. He has had a nerve stimulator from 2013 to 2015 that was removed due to infection. His current medications include diclofenac, Lidocaine cream, Lyrica, and Percocet. He tried Morphine but developed a rash and sedation. He has tried OxyContin with pain reduction from 8/10 to 1/10 visual analogue scale (VAS).  The Health plan believes he needs to try other non-narcotic medications and another trial of Morphine. The physician does have an opiate maintenance agreement in place and urine toxicologies have been negative for drugs of abuse. There is a plan to taper his opiates after surgery is successful and completed.  Researchers reviewed current clinical practice guidelines and note the use of opiates as a third line medication is acceptable in treating neuropathic pain. Similarly, a study of 16 clinical practice guidelines reinforced this approach as an acceptable method of pain control. The patient has an allergy to morphine and is on multiple non-narcotic medications for pain and is participating in physical therapy. The OxyContin provides ample pain relief (from 8/10 to 1/10 VAS).  Therefore, the requested medication is medically reasonable and necessary.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 anesthesiology with a subspecialty certification in pain management 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 Cartiva synthetic cartilage implant surgery.Findings:  Two of the three physician reviewers found Advanced stages of first metatarsophalangeal arthritis have traditionally been treated with various arthroplasties or arthrodesis. While the medical literature does show some early promising results with the use of the Cartiva synthetic cartilage implant for the treatment of hallux rigidus, there is a lack of long-term high-quality studies demonstrating safety and efficacy. The gold standard for treatment of hallux rigidness remains arthrodesis. Per the records, this patient has mild to moderate intermittent symptoms. There are no submitted reports of radiology studies which grade the severity of the degenerative changes of the great toe metatarsophalangeal joint. In sum, Cartiva synthetic cartilage implant surgery is not likely to be superior over other 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 reviewers 1, 2 and 3 are board certified in orthopedic 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Lyrica. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees occipital neuralgia and neuritis.At issue in this case is whether the requested medication Lyrica is medically necessary for treatment of the patients medical condition.A study noted that pregabalin (Lyrica) is a very effective agent for the treatment of neuropathic pain and has a very good safety profile. The patient has trialed and failed treatment with use of tricyclic antidepressants (amitriptyline); and anti-convulsants (gabapentin); as well as topical Lidoderm. The patient has reported good pain relief with Lyrica samples provided by the physicians office. Therefore, given the failure of previous medications and proven efficacy of Lyrica in this patient, the requested medication is medically necessary.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 subspecialty 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.