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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for adjuvant radiation therapy with a tertiary care provider for treatment of the enrollees recurrent embryonal rhabdomyosarcoma. Findings:  The physician reviewer found that the patient is recommended to receive standard adjuvant therapy for a shoulder sarcoma. There is no data submitted that suggests that the in-network provider is not capable of delivering standard radiation treatment in the postoperative setting for a shoulder lesion. Furthermore, there is no data to suggest that treatment at USC Norris Cancer Center will be associated with improved outcomes or less toxicities compared to the in-network provider. 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 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: The parent of a 16-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee for evaluation of the enrollees osteochondritis dissecans of the left knee. Findings:  The physician reviewer found that the current medical literature supports the medical necessity of MRI scans in decision making for juvenile osteochondritis dissecans of knees. According to Samora and colleagues, recent data suggest that MRI is the best method for analyzing the status of the cartilage and subchondral bone in patients with juvenile osteochondritis dissecans. The authors concluded that MRI continues to be reliably sensitive to juvenile osteochondritis dissecans lesions and is a good predictor of low-grade, stable lesions. Bauer and Polousky reported that treatment decisions in patients with osteochondritis dissecans should be based on MRI findings and not x-ray findings, although the diagnosis is made on x-ray findings. For these reasons, the requested MRI scan of the left knee is appropriate and medically necessary for decision making with regard to further treatment of this patients osteochondritis dissecans of the knee. Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prednisone for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case. Fibromyalgia is a chronic pain disorder that is treated with a number of non-pharmacologic and pharmacologic therapies provided in combination. These medications include selected antidepressants and selected anticonvulsant medications. Prednisone is U.S. Food and Drug Administration (FDA) approved for use in certain rheumatic disorders that cause chronic pain and debility.  It is FDA approved for use in an exacerbation or as maintenance therapy in selected cases of ankylosing spondylitis, dermatomyositis/polymyositis, polymyalgia rheumatica, psoriatic arthritis, relapsing polychondritis, rheumatoid arthritis, including juvenile rheumatoid arthritis, Sjogrens syndrome, systemic lupus erythematosus and vasculitis, as well as other conditions. However, the current medical evidence does not support the use of prednisone in this clinical setting. Prednisone is not indicated for the treatment of chronic pain caused by fibromyalgia. All told, prednisone is not medically necessary for the treatment of this patient. 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patient was showing mild post-acute withdrawal symptoms.  He was not a danger to himself or others, and was not having self-harming urges.  He was medically stable. His general anxiety disorder was not out of control, and he did not require a confined and structured setting. He was engaged and working the program. He knew his triggers and was well versed in steps. He was utilizing meditation and mindfulness techniques.  Naltrexone was restarted on 6/21/17.  In groups, he demonstrated a good understanding of the 12-step program evidenced by his ability to describe and explain steps 8 and 9 to others based on prior work with his sponsor.  He denied suicidal or homicidal ideation.  His pulse was 110, blood pressure 132.97.  Medications included Cymbalta and Clonidine.  He had found a sober living environment and planned to start hepatitis C treatment.  He was sent to the emergency department due to an episode of palpitations and shortness of breath. His pulse was 132. His tachycardia, future hepatitis C treatment, and naltrexone/Vivitrol could have been managed on an outpatient basis. He no longer required 24 hours per day, 7 days a week supervision, and could have been stepped down to an ambulatory level of care. In sum, residential treatment care was not medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for fluorouracil 5% cream for treatment of the enrollees verruca vulgaris. Findings:  The physician reviewer found that the records provided for review document that this patient has tried and failed therapy with liquid nitrogen as well as cantharone plus. However, the requested medication, fluorouracil 5% cream has not been U.S. Food and Drug Administration (FDA) approved for the treatment of verruca vulgaris in the pediatric population. Given that the patient is an eight-year-old, the requested fluorouracil 5% cream is not supported as medically necessary for treatment of recalcitrant verruca vulgaris. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX Reflux Management System for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  The 3 physician reviewers found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient has evidence of GERD based on pH recording. However, the patient has benefited to a significant degree from Dexilant treatment, and as such he cannot be considered medically refractory to acid blocker drugs. Also, implantation of LINX in the patients clinical setting must be approached with caution given his manometric evidence of peristaltic dysfunction which may predispose to procedure-associated dysphagia. In addition, LINX is not U.S. Food and Drug Administration (FDA)-indicated in patients with Barretts esophagus or sizable hiatal hernias. As such, the LINX Reflux Management System is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a myoelectric prosthesis socket that is used for activities of daily living, such as getting dressed, used in classes at school, making food, two-hand holding of objects, and a body-powered prosthesis socket that has different terminal devices to aid the activities of daily living, such as the enrollees physical education class for treatment of the enrollee, who has been diagnosed with left wrist congenital transverse deficiency with radial head dislocation. Findings:  The physician reviewer found that the medical literature indicates that the prosthesis is a fabricated substitute for missing limbs. Myoelectric prostheses are recommended for patients who have sufficient neurological, myocutaneous and cognitive function to operate the prosthesis effectively.  There should be evidence that standard body-powered prosthetic devices cannot be used or that they are insufficient to meet the functional needs of the patient to perform activities of daily living. Body-powered prostheses have been shown to have the advantage of durability, frequency of adjustment, and maintenance. However, they could still benefit from improvement in control. Myoelectric prostheses have been shown to improve cosmesis and phantom-limb pain and are more accepted for light intensity work.  Prosthetic selection should be based on the patients individual needs and include personal preference, prosthetic experience and functional needs. The documentation provided for review indicates that the patient has a myoelectric and body-powered socket.  The patient utilizes her myoelectric socket for activities of daily living such as getting dressed, school, making food and two-hand holding of objects. The patient utilizes the body-powered socket during activities of daily living and during gymnastics and BMX biking.  It was noted that the patient did have radial head dislocation with tenderness over the radial head.  However, it was noted in the documentation that the patient was to wear her prosthesis for six months and then if pain was unbearable, surgery would be considered.  There was no clear rationale as to why the patient cannot continue to utilize the prostheses that have previously been provided as per her providers recommendations.  Therefore, the requested equipment is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nerve block peripheral injection for treatment of the enrollees knee pain.Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. The medical records lack documentation of a physical examination demonstrating knee pain due to neuralgia of the genicular nerves. Additionally, there is a lack of documentation of failed standard therapy with antidepressants and anticonvulsants for neuropathic pain. One study performed a double-blind, randomized clinical study comparing neurolysis using traditional radiofrequency to local anesthetic and corticosteroid block of the superolateral, superomedial, and inferomedial branches of the knee genicular nerves in patients who had total knee arthroplasty but still experience pain. The authors noted further clinical trials need to be undertaken, with a larger sample size, in order to demonstrate the efficacy of this technique and to detect the possible appearance of any long-term adverse effects. Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for light treatment (ultraviolet B) system for use in the home (UVB narrow band phototherapy home booth for treatment of the enrollees vitiligo. Findings:  The 3 physician reviewers found that vitiligo is an acquired pigmentary disorder of the skin and mucous membranes characterized by circumscribed depigmented macules and patches that cause significant morbidity due to cosmetic disfigurement. Treatment for vitiligo is difficult and prolonged. Although many therapeutic options exist and new modalities are still emerging, treatment challenges persist, as not all patients respond to standard available therapies. Variables that affect the choice of treatment include the extent, distribution, and progression rate of the lesions. Medical treatments include topical corticosteroids and other topical treatments, such as Protopic. This patient has tried and failed the standard medical therapies. Vitiligo can be treated with narrow band ultraviolet B (NBUVB) and studies have shown its efficacy. Thus, NBUVB is an established modality for treatment of vitiligo. In sum, light treatment (ultraviolet B) system for use in the home (UVB narrow band phototherapy home booth) is likely to be more efficacious than the other modalities available for the treatment of this patients medical condition.  Final Result: The 3 reviewers determined that the requested equipment is 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 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: An enrollee has requested authorization and coverage for Praluent for treatment of the enrollee who has a history of coronary disease. Findings:  The physician reviewer found that The documentation provided supports the medical necessity for the requested medication in this clinical setting. Based on the records provided the patient has known coronary disease, elevated LDL cholesterol and documented inability to tolerate both statins and Zetia.  In this circumstance, a trial of a PCSK9 inhibitor is reasonable, appropriate and now considered standard accepted practice in the medical community.  PCSK9 inhibitors such as Praluent have been studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  This patient meets the latter criteria since his LDL is elevated above goal and there is documented intolerance to both statins and Zetia which was used in an effort to lower LDL.  There is significant scientific literature that documents outcome benefits using PCSK9 inhibitors in this setting. For these reasons, Praluent is medically necessary for treatment of this 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical therapy, twice a week for treatment of the enrollee who has a history of pelvic and vaginal pain.Findings:  The physician reviewer found that chronic pelvic pain syndromes are not uncommon and can cause impaired quality of life.  These pain syndromes, including pudendal neuralgia, are poorly understood, and there is limited high-grade evidence available to guide treatment. In the current case, there are no objective indications that the formal physical therapy services that the patient had been receiving had been effective. Despite the therapy interventions that were being provided, the patient reported persistent symptoms that prompted her to ultimately undergo left pudendal nerve cryoablation in early May 2017. She continued to have pain, functional limitations and urgency/frequency.  She sought further treatment and was even referred to urogynecology for possible botulinum toxin injection to the muscles.  It was noted in the urogynecology consultation record that the benefits from physical therapy had essentially been exhausted.  Further pelvic physical therapy would not be reasonably expected to be effective in improving the patients clinical course or outcomes.  The patient and her spouse have been trained to provide palliative manual therapy, which would be expected to be no less effective than ongoing formal physical therapy.  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 physical medicine and rehabilitation 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.