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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections. Findings:  The physician reviewer found that Intraarticular injections of hyaluronic acid are an established part of treatment algorithms for management of osteoarthritic knee pain and are generally considered a second-line treatment after medications such as nonsteroidal anti-inflammatory drugs (NSAIDs). Multiple studies have documented the efficacy of intraarticular hyaluronic acid injections for osteoarthritic knee pain. Hyaluronic acid is present in joints and there is no evidence that additional hyaluronic acid or repeat hyaluronic acid injections are unsafe.  A study noted that, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months... All told, the requested intraarticular Orthovisc injection is medically necessary in this patient with osteoarthritic knees despite multiple medications and failed corticosteroid injection.Final Result: The reviewer determined that the requested service 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 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: The parent of an enrollee has requested authorization and coverage for shoe inserts (orthotics) for treatment of the enrollees ankle pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested shoe inserts. Shoe inserts are indicated in limited circumstances. Inserts and other shoe modifications such as lifts, wedges, arch supports are indicated if they are on a shoe that is an integral part of a medically necessary leg brace for the proper functioning of the brace. Review of the documentation submitted does not support the treatment recommended. 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 podiatry 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 deep vein thrombosis (DVT) prevention system (E0673  segmental gradient pressure pneumatic appliance, half leg). Findings:  Two physician reviewers found that minor injuries in the leg are associated with greater risk of venous thrombosis. A venous thrombosis is a blood clot that forms within a vein. DVTs form in the deep veins of the legs, and if a piece of a blood clot formed in a vein breaks off it can be transported to the right side of the heart, and from there into the lungs, also known as venothromboembolism (VTE). A retrospective study of more than 7,000 podiatry patients identified a low overall risk of VTE in podiatric surgery, suggesting that routine prophylaxis is not warranted. Intermittent pneumatic compression devices are recommended for short-term mechanical thromboprophylaxis for moderate- to high-risk perioperative surgical and hospitalized patients, especially following lower extremity trauma. Best practices involve use of simple and practical lower leg-only devices, combined with pharmacological thromboprophylaxis when medically feasible. In this case, the documentation submitted for review does not demonstrate that the patient has any risk factors for developing VTE. Moreover, surgery of the foot and ankle has a very low incidence of VTE. In sum, the peer-reviewed literature does not support the device at issue in this low risk patient undergoing ankle surgery.Final Result: The reviewers determined that the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  Two physician reviewers found that guidelines for the management of cardiac risk and dyslipidemia have been established and these guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phosholipase A2 (Lp-PLA2), Apo-lipoprotein B, sub-classifications of low density lipoprotein (LDL) cholesterol, high density lipoprotein (LDL) cholesterol subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment changes or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Further, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewers are 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 Repatha Sureclick 140 mg/mL pen injector. Findings:  The physician reviewer found that the medical literature showed that Repatha is an effective alternative to patients that have statin intolerance or cannot take statin such as this case. According to the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines, this patient is already on maximum high intensity statin therapy with atorvastatin 80 mg and she has not achieved 50% reduction. Moreover, the patient has coronary artery disease so it is important to decrease her LDL-C beyond current levels and this can be done by adding Repatha to her regimen. Furthermore, the patient must stop statin therapy due to hepatitis, therefore Repatha is a safe non-statin alternative to decrease LDL-C. 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 endocrinology, diabetes, and metabolism 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 child enrollee has requested 51.6 hours per month of one-on-one applied behavioral analysis (ABA) therapy for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that there is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. In this case, the patient demonstrates multiple problematic behaviors which include aggression, inflexibility/non-compliance and eloping. These behaviors place the patient at significant risk given her lack of awareness. In addition, the patients unwillingness to participate in low preference transitions within the community has made it increasingly difficult for her to demonstrate mastery of her adaptive skillsets and behavioral goals. Final Result: The reviewers determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 Botox treatment for his jaw pain. Findings:  Three physician reviewers found that Botox therapy is not approved by the U.S. Food and Drug Administration (FDA) for treatment of TMJ disorders. There is a lack of consensus in the peer-reviewed literature regarding the efficacy of Botox for the treatment of TMJ disorders due to limited studies and conflicting results. There is some literature that indicates that use of Botox in the treatment of TMJ disorders may cause decreased bone density of the condyles, indicating that this treatment may be harmful. Final Result: The reviewers determined that the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in dentistry and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency ablation for treatment of her metastatic breast cancer. Findings:  Two physician reviewers found that radiofrequency ablation of liver metastases is often used in situations where the lesions cannot be surgically excised. Most of the data relevant to radiofrequency ablation treatment of liver metastases is in the treatment of colon cancer. Although it is a treatment used reasonably often, there has been conflicting data as to its efficacy, and in whom it should be used. Researchers reported on a series of studies done in breast cancer patients.  The authors concluded that the technique could be considered in patients who either had no extrahepatic disease or stable extrahepatic disease. The criteria for the applicability of the technique were the same as reported in another study.  In this patients case, the records documented metastases to the lung and bones, as well as a liver metastasis which was 9 mm in size.  Per the records, there was some degree of progression of these extrahepatic metastases. There is a lack of support for the services at issue in this setting.  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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for Afirma gene expression classifier for evaluation of his thyroid nodules. Findings:  Three physician reviewers found that there are multiple peer reviewed scientific articles indicating the benefits of the genetic test in thyroid nodules. In this patients case, the cytopathology of the thyroid nodule was consistent with FLUS. The medical literature indicates that the risk of malignancy is between 5 to 15% in FLUS. The Bethesda System recommends a repeat biopsy for this type of nodule. The 2015 American Thyroid Association's guidelines state that for nodules with AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. This patients nodule is hypoechoic and is enlarging, which are worrisome features. If the genetic test is suspicious, the risk of malignancy increases to 40%. The risk of malignancy decreases to less than 6% with benign findings by gene expression classifier (GEC). In this patients case, the result of the Afirma GEC was suspicious for malignancy. This information was important to determine whether to perform thyroidectomy or not and the extent of surgery, hemi-thyroidectomy versus total thyroidectomy. The test is in vitro, which confers minimal physical risk to the patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Decision DX Melanoma Gene Expression Assay for evaluation of her cutaneous melanoma.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the testing at issue. The use of Decision DX testing is not recommended outside of clinical trials according to the National Comprehensive Cancer Network guidelines. In addition, the testing at issue is not the standard of care in melanoma treatment or work-up. Final Result: The reviewer determined that the testing at issue was not medically necessary for evaluation 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 total knee arthroplasty with ConforMIS Custom Implant for treatment of her knee osteoarthritis. Findings:  Three physician reviewers found that patient-specific instrumentation is a modern technique in total knee arthroplasty aiming to facilitate the implantation of the prosthesis minimizing errors in sizing, alignment, and rotation. However, review of the current literature does not indicate its recommendation as the gold standard in conventional non-complicated total knee arthroplasties. It has advantages over the conventional total knee arthroplasty in the presence of deformities, fracture malunions, and when intramedullary alignment cannot be used.  However, for a standard total knee arthroplasty such as in this case, the current literature does not support the use of patient specific instrumentation. Per the medical evidence, the requested services are not likely to have a better result compared to the standard total knee arthroplasty. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in orthopedic surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Rytary 23.75-95 mg capsule ER for treatment of her Parkinsons disease. Findings:  The physician reviewer found that Parkinsons disease is a progressive neurodegenerative disorder that is treated with dopamine agonist, and combination products of levodopa/carbidopa. Immediate-release versions of this can result in considerable on/off and dyskinetic variations.  In general, the standard extended-release version has only modest improvement compared to the standard immediate-release. Rytary has a combination of extended-release and immediate-release beads.  Rytary has been shown to have better pharmacokinetics, and clinically, to minimize motor fluctuations and peak dose dyskinesias. Rytary is considered a first-line regimen, with better clinical results. There is no clinical value in switching a patient from a proven regimen with good results, to an untried regimen. 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 number 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy for treatment of his prostate cancer.  Findings:  Three physician reviewers found that the request for proton beam radiation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is some medical literature supporting the safety and efficacy of proton beam radiation therapy for the treatment of prostate cancer. However, there is a lack of randomized trials suggesting superior clinical outcome for prostate cancer over standard therapy such as intensity-modulated radiation therapy (IMRT). Additional studies for long-term safety and efficacy are needed comparing protons with photons for the treatment of prostate cancer. The National Comprehensive Cancer Network (NCCN) guidelines indicate that proton therapy is an option for prostate cancer, but no clear benefit over the existing therapy of IMRT has been demonstrated. Given the lack of peer-reviewed literature supporting proton radiation therapy for prostate cancer, the requested services are 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 12 sessions of physical therapy per month.Findings:  The physician reviewer found that although a multidisciplinary approach to spine pain including physical therapy may be beneficial, the goal of physical therapy is to transition patients to an independent home exercise program without continued dependence on supervised therapy. The additional requested therapy is not accepted as specific and effective therapy for this patients condition. The documentation does not indicate that prior extensive physical therapy has resulted in significant objective increase in overall function. The services at this point do not need to be under the supervision of a therapist. The patient has had extensive prior physical therapy and should be well versed in a home exercise program. The expected rehabilitation potential is not significant in relation to the extent and duration of the physical therapy services requested. The specialized skill of a qualified therapist is not required to establish, design or deliver a maintenance program to maintain the patients current condition or to slow further deterioration. For these reasons, the requested 12 sessions of physical therapy per month are not medically necessary for treatment of this patients medical conditionFinal 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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.