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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Proton Beam Radiation Therapy for newly diagnosed moderately differentiated adenocarcinoma of the gastroesophageal junction. History included reflux esophagitis and Barretts esophagus. The enrollee indicated being in good health until he noticed having difficulty eating, with a sensation of food getting stuck, leading to substantial weight loss.  PET/CT showed no metastatic disease and a mass in the distal esophagus. Medical oncology recommended treatment including concurrent chemotherapy with radiotherapy, followed by surgical resection. The enrollee presented to Radiation Oncology regarding the role of proton therapy in the treatment of his cancer. After discussion, the patient opted for the proton beam radiation therapy. Three of three reviewers indicated that the medical literature does not support this treatment as a Group 1 or highly recommended treatment for esophageal cancer. The literature indicates proton beam is appropriate in clinical settings where reduction in dose to organs, such as heart and lungs is required.  Based on the medical documentation, that is not an issue in this case and there is no evidence supporting a meaningful difference in the clinical outcome with proton beam radiation therapy. The data supporting the use of proton beam radiation therapy in this setting are early and evolving and treatment under this circumstance should be as part of a clinical trial.  Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Proton Beam Radiation Therapy for a diagnosis of malignant neoplasm of the connective and soft tissue with history of Hodgkins lymphoma that were treated with chemotherapy and radiation. The enrollee developed synovial sarcoma in the mediastinum and had a resection and then developed metastatic disease with a recurrence in the abdomen. He underwent proton beam radiation therapy.  The enrollees Radiation Oncologist indicates the tumor is located in very close proximity to many critical organs  the heart, lungs, esophagus, spinal cord, liver, and bowels. As a result, in order to deliver adequate radiation to this location, proton therapy was recommended. It is noted that with an absence of exit radiation, proton beams can deliver radiation to target in close proximity to critical structures while minimizing the risks of acute and late toxicity. Two of the three reviewers determined that according to the medical literature, proton beam radiation therapy is indicated, specifically in this case, due to previous radiation received in treatment. The literature indicated proton beam therapy would deliver a lower dose to spare critical structures. One reviewer determined the proton radiation did not offer a significant advantage over the standard treatment. Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is overturned.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether the MaterniT21 PLUS (Core) that was provided was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy. A review of the records indicates the patient was estimated to be 16.9 weeks gestation by ultrasound and underwent a prenatal screen. The results from that screen indicated an increased risk for Down syndrome. The provider ordered a MaterniT21 PLUS (Core).Findings:  Three physician reviewers found that the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin Number 163, states that women with a positive screening test result for fetal aneuploidy should be offered further counseling and cell-free deoxyribonucleic acid (DNA) screening or diagnostic testing by chorionic villus sampling or amniocentesis. There are a wide variety of screening test options, and no one screening test is superior to other screening tests in all test characteristics (ACOG). This patient had a positive quad screen, which indicated that she was at an increased risk of having a fetus affected by a genetic disorder. Confirmation with cell free fetal DNA screening was appropriate to assess for aneuploidy.Final Result: The reviewers determined that the requested evaluation was likely to have been 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 obstetrics and gynecology 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 cardiac ablation. Findings:  Three physician reviewers found this patient has symptomatic, frequent, premature ventricular contractions. Based on the electrocardiogram, these may be of right ventricular outflow tract origin. He has failed a trial of medical therapy with a calcium channel blocker. As it appears his symptoms are more frequent at rest and improve with exercise, it is unlikely that other therapies, such as beta-blockers, would be effective. Catheter ablation is an appropriate treatment in this clinical setting. The procedure has a high success rate, a low incidence of complications, and may provide an improvement in quality of life. Thus, the requested cardiac ablation is likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested services are 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 internal medicine with sub-specialty certification in cardiovascular disease 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: A patient is requesting authorization and coverage of Vivitrol 380 mg vial. Findings:  The physician reviewer found that the patient reportedly began treatment with injectable naltrexone. It was noted treatment with naltrexone has been successful. The patient was noted to have maintained his sobriety. At issue in this case is whether Vivitrol 380mg vial is medically necessary for the treatment of this patients medical condition. Vivitrol is indicated for the treatment of alcohol dependence. A study reported that shortterm treatment with Vivitrol has been shown to decrease the chance of alcohol relapses by 36% and is likely to reduce the chance of returning to drinking by 13%. In addition, the authors found that Vivitrol lowered the risk of withdrawal in 28% of alcoholdependent patients. Naltrexone is an effective and safe strategy in alcoholism treatment. This patient has documented benefit from treatment with injectable naltrexone and has maintained abstinence from alcohol for five months. Therefore, Vivitrol 380mg vial is medically necessary for 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 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

The enrollee has requested reimbursement for fertility preservation services received. The Health Plan has denied the services at issue as not medically necessary.The American College of Obstetricians and Gynecologists (ACOG) indicates that an important clinical predictor of outcomes in the observational studies of oocyte preservation and in-vitro fertilization is the age of the oocyte when frozen or vitrified. Outcomes of four published randomized controlled trials demonstrated that fresh and frozen oocytes yield similar pregnancy rates in in-vitro fertilization cycles, supporting the use of these technologies in well-selected patients aged 35 years and younger. The medical records for this female patient indicate that cryopreservation of oocytes was performed at the age in anticipation of breast cancer therapy. However, the age exceeds the currently recommended limit for oocyte cryopreservation because this age is already subject to primary ovarian insufficiency and aneuploidy. 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with lipedema. The patient endorsed leg and hip pain for over 12 years. A computed tomography (CT) scan of the patients abdomen was unremarkable. A venous ultrasound of the patients legs was noted to be normal. The patient complained of fullness in the upper and lower extremities with bruising, swelling, and pain that was not responsive to diet and exercise. The patient reported that the pain affects her activities of daily living. The patient has been treated with gabapentin, Voltaren gel, compression stockings, and ice and heat. a few months later, the patients body mass index (BMI) was 43. The patients photographs were reviewed. At issue in this case is whether lipedema lymph sparing liposuction surgeries to the calves, ankles, upper buttocks, hips, upper arms, to circumferential thighs, employing multiple modaities of Water Assisted Liposuction (WAL), VASER (ultrasonic), and Power Assisted Liposuction (PAL) using local anesthesia and manual lymphatic drainiage therapy are medically necessary for the treatment of the patients medical condition. As noted by researchers, lipedema is characterized most commonly by disproportionate adipocyte hypertrophy of the lower extremities, significant tenderness to palpation, and a failure to respond to extreme weight loss modalities. The authors found that due to lipedemas relatively unknown status in the medical community, there is a paucity of data regarding effective treatments of this disease. Relatively few studies have defined the precise pathogenesis, epidemiology, and management strategies for this disorder. This patients records do not document failure of conservative management, including significant weight loss, as the patient reportedly has a BMI of 43. Therefore, lipedema lymph sparing liposuction surgeries to the calves, ankles, upper buttocks, hips, upper arms, to circumferential thighs, employing multiple modaities of WAL, VASER (ultrasonic), and PAL using local anesthesia and manual lymphatic drainage therapy are not medically necessary for the patient. 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Synvisc-One injections. The Health Plan has denied the requested services as investigational for treatment of the enrollees osteoarthritis of the knees.Findings:  The physician reviewers found that the requested injections are not likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Findings:  Two out of three physician reviewers found that the guidelines for treatment of osteoarthritis of the knee does not recommend hyaluronic acid (HA) for patients with symptomatic osteoarthritis, based on strong evidence. Fourteen HA studies were analyzed, and it was noted that a few individual trials found statistically significant treatment effects, but when combined in a meta-analysis, the evidence did not meet their minimum clinically important improvement thresholds. It was conceded that there might be some subgroup of responders who could be helped by HA, but that subgroup has not yet been identified. In this case, the clinical documentation does not include imaging reports demonstrating the presence of severe osteoarthritis. Further, the records do not report that the enrollee is having pain that interferes with functional activities or has failed treatment with intra-articular corticosteroid injections. Thus, the Synvisc-One injections are not likely to be more beneficial for treatment of the enrollees condition than any available standard therapy. One physician reviewer found that viscosupplementation is recommended in enrollees with a history of lasting benefit from prior injections and in carefully selected cases where conservative modalities have failed and the remaining treatment options are limited. In this case, there is known benefit from a Synvisc-One injection of the right knee, and the options are limited, with the alternative being a total knee arthroplasty. As such, Synvisc-One injections are likely to be more beneficial for treatment of the enrollees condition than any available standard therapy.Final Result: The reviewers determined that the requested injections are not likely to be more beneficial for evaluation of the enrollees 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for a positron emission tomography (PET) scan. There is no cytological diagnosis of cancer in this patient included in the records provided for review. The patient reports the lesion at T11-12 is a Schwannoma, which is a benign nerve sheath tumor not prone to metastases. Evaluation for local growth is recommended with magnetic resonance imaging (MRI). The patient was evaluated with MRI scans both pre-operatively, and post-operatively, which were interpreted as unchanged. The literature shows some potential benefit of PET in searching for spinal metastases when a malignant primary tumor has been confirmed. However, there is a lack of evidence that PET is useful in differentiating a benign Schwannoma from a malignant nerve sheath tumor. All told, the requested PET scan is not supported as medically necessary for further evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 25 hours per week of direct one-to-one applied behavior analysis (ABA) services (CPT 97153). This patient has made considerable progress. His Vineland 3 scores have all improved since baseline, with an adaptive behavior composite score of 72. This score places him within two standard deviations of the mean, or the moderately low range. Overall, this is an improvement compared to baseline, an indication that the gap between the patient and his same-aged peers is gradually closing. Further, the patient has several goals listed in the treatment plan involving reduction in problem behavior. However, the treatment plan has listed the severity of the behaviors in the low range, with the exception of elopement. These behaviors have also decreased over previous treatment periods, indicating the patient continues to make progress, albeit with fewer treatment hours. A letter from the provider indicated that since the treatment was reduced at the start of the year, there was a relatively small spike in problem behavior likely due to the addition of several new peer contexts that he could not access before due to the frequency and intensity of his problem behavior. Considering this information, the patient is responding to treatment, his goals do not reflect a need for greater intensity, and the patient has not demonstrated a need for a greater intensity of service delivery. The Health Plan has authorized 20 hours per week of direct one-to-one ABA services, which is appropriate given this patients progress and remaining goals. Thus, the requested 25 hours per week of direct one-to-one ABA services (CPT 97153) are not medically necessary for treatment of this patients autism. 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 psychology and is a board certified behavior analyst 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: The patient has requested reimbursement and prospective authorization and coverage for occipital nerve block injections. Occipital nerve blocks are considered the standard of care for this patients diagnosis of occipital neuralgia. Researchers found that occipital nerve block with a local anaesthetic and corticosteroids provides a safe, simple, and effective treatment method for the patient with medically-refractory occipital neuralgia. The records provided for review document that this patient presents with new onset chronic daily headache after laminectomy. The provider reports the patient has failed two standard medications for this condition, gabapentin and nortriptyline. In addition, the records report the patient experienced an improvement in symptoms with occipital nerve blocks. Given this support, the occipital nerve block injections were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the services at issue were and are 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:  One reviewer is board certified in neurology with subspecialty certification in in neuromuscular medicine and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology with subspecialty certification in sleep medicine 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.