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

Nature of Statutory Criteria/Case Summary: An enrollee is requesting coverage of residential services.The diagnoses are opioid use disorder severe, sedative hypnotic use disorder severe and major depression recurrent in remission. The enrollee underwent brain surgery and has had continued seizures since that time. The enrollee has a history of medication noncompliance, and a history of multiple overdoses; most recently, the patient impulsively ingested two bottles of Seroquel. There is mention of discharge from mental health inpatient, with stepdown to partial hospitalization program (PHP).On admission to residential, and thereafter, the patient's withdrawal symptoms were not of a severity necessitating 24/7 monitoring as evidenced by her COWS and CIWA scales. The patient denied suicidality or homicidally, and was not depressed. The enrollee clearly showed poor impulse control, however this is not a criterion in and of itself for residential admission. There were no emotional or behavioral factors necessitating residential level of care. The enrollee was medically and psychiatrically stable. The patient had some social supports available in that the discharge plan was for the support system members. The patient had an outpatient therapist. Based on the findings treatment could have been rendered in an ambulatory setting, therefore residential level of care was not medically necessary.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 upheld.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Optune device. Findings: Three physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Researchers have presented a case report of a long term survivor with recurrent GBM that was treated with NovoTTF. Furthermore, National Comprehensive Cancer Network (NCCN) guidelines now include Optune TTF therapy in their treatment flow charts, and follow up analyses have confirmed earlier findings relating to the treatment efficacy of TTF therapy. In this case, the patient has diagnosed GBM, and she has exhausted standard treatment options. Under these circumstances, the Optune device provided to the patient was likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with subspecialty certification in medical oncology, and they 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: This patient relates the development of a severe headache followed by total body pain. This episode has lasted 3 months. There have been hospitalizations and visits to the emergency room to deal with pain. The patient has had trials of opiates, gabapentin, muscle relaxants and Zanaflex without significant improvement. The patient has found relief with intravenous ketorolac and intravenous acetaminophen. The patient requests additional intravenous administration of these medications.These two medications are both available in oral form and the patient has not described any inability to take medications orally. The bioavailability and pharmacokinetics of these medications are not clinically significant when taken in oral form as compared to intravenous form. The requested intravenous administration is not medically reasonable or necessary.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 in anesthesiology, with 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 reimbursement for MHTFR gene testing.Findings: Three of the three physician reviewers found that the MHTFR gene testing provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The American College of Medical Genetics (ACMG) recommends against testing anyone for MTHFR variants, including those with a known family history of polymorphisms, as there is no clinical utility in such testing. In fact, MTHFR testing was included in the ACMGs recent list of tests not to order as part of the Choosing wisely campaign. There is no known treatment recommended for those who have 1 or 2 copies of these polymorphisms. Therefore, the MHTFR gene testing performed for the patient was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: Three of the three reviewers determined that the MHTFR gene testing provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: One reviewer is board certified in genetics and clinical biochemical genetics and is actively practicing. One Reviewer is board certified in genetics and is actively practicing. One Reviewer is board certified in genetics 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 CARIS Tumor Genetic and Antibody Testing.Findings:  Two of the three physician reviewers found CARIS Tumor Genetic and Antibody Testing is a type of molecular profiling. It has not been established if molecular markers are useful in treatment determination (predictive markers) and prognosis other than for KRAS, NRAS, and BRAF mutation testing and microsatellite instability (MSI) or mismatch repair (MMR) testing. Multiple clinical trials that are attempting to validate this personalized or precision medicine approach are in various stages of development and execution. Although preliminary data from some of these efforts have fueled excitement about the value and utility of these studies, their execution has also provoked many questions about the best way to approach complicating factors such as tumor heterogeneity and the choice of which genetic mutations to target. At this time, it is unclear if molecular profiling is beneficial in identifying potential targets for treatment. In sum, CARIS Tumor Genetic and Antibody Testing are not likely to be superior over other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery to implant a hypoglossal nerve stimulator.Findings:  Two of the three physician reviewers found Obstructive sleep apnea is an increasingly prevalent clinical problem with significant effects on both personal and public health. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea. This trial has demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed CPAP, have nonconcentric airway collapse, an AHI between 20 and 50, and a BMI less than 32. With a BMI of 31, AHI of 39 and without complete concentric airway collapse, this patient meets the criteria for implantation with a hypoglossal nerve stimulator. He has failed CPAP, which is the gold standard treatment for obstructive sleep apnea. Therefore, surgery to implant a hypoglossal nerve stimulator is likely to be more effective 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 otolaryngology 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 Euflexxa injections. The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollees right knee osteoarthritis.A review of the record indicates the enrollee was diagnosed with right knee osteoarthritis. Prior conservative treatment included oral medication, bracing, and corticosteroid injections. There was an excellent response to prior administrations of viscosupplementation. There was documentation of subjective, objective, and radiographic imaging results consistent with the diagnosis of advanced osteoarthritis. As such, the request for Euflexxa injections of the right knee is reasonable, appropriate and medically necessary.Final Result: The reviewer determined that the requested services 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for food allergy panel testing. Findings:  Two of the three physician reviewers found that there is a lack of support for the services at issue in this patients case. A study noted testing for blood IgG against different foods is performed with large-scale screening for hundreds of foods. However, many serum samples show positive IgG results without corresponding clinical symptoms. These findings, combined with the lack of convincing evidence for histamine-releasing properties of IgG in humans, and lack of any controlled studies on the diagnostic value of IgG testing in food allergy, do not provide any basis for the hypothesis that food-specific IgG should be attributed with an effector role in food hypersensitivity. IgG diagnostic testing, which includes IgG food sensitivity and IgG subclass testing, is not clinically useful, relevant, or a valid method for evaluating for food allergy, or dermatitis due to an ingested food, or food intolerance that may be contributing to dermatitis or other skin or allergic condition. Therefore, food allergy panel testing was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in pediatrics and allergy and immunology and are actively practicing. Physician reviewers 2 is board certified in allergy and immunology 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 Orthovisc injections. The Health Plan has denied this request indicating that the requested injections are not medically necessary for treatment of osteoarthritis. Despite the lack of recommendation by the American Academy of Orthopedic Surgeons in 2013, the current medical literature subsequent to that date continues to support the use of viscosupplementation for osteoarthritis of the knees. This is due to the relatively good results from its use. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. The subjective and objective findings were consistent with the diagnosis. This individual had failed conservative treatment. As such, the request for Orthovisc injections of the right knee were found to be reasonable, appropriate, and medically 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 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.Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for subcutaneous testosterone implants. Findings:  Three physician reviewers found that the documentation fails to demonstrate the superior efficacy of the services at issue. Any medication that improves serum testosterone to normal range is likely to improve the symptoms if the etiology is strictly the low testosterone. Testosterone replacement was indicated based on the patients laboratory values and symptoms. The medical evidence has not demonstrated that Testopel is more beneficial than other forms of hormone therapy. Thus, subcutaneous testosterone implants were not likely to have been of greater benefit than other available treatment options. 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: Physician reviewers 1, 2 and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing.Findings: Three of the three physician reviewers found that the advanced lipoprotein testing provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Advanced lipid testing measures subpopulations of lipoproteins and apolipoproteins which include lipoprotein(a) (Lp[a]), apolipoprotein A-I (ApoA-I), apolipoprotein B (ApoB), and measures of lipoprotein particle composition such as LDL and HDL particle number and particle size. Guidelines from 2013 do not recommend advanced lipoprotein testing which includes ApoB for cardiovascular risk assessment. At this time, the clinical utility of using the advanced lipid testing for assessment of cardiovascular risk is unclear. There is also a lack of clinical documentation to support the indication for advanced lipid testing for this patient. Therefore, the advanced lipoprotein testing provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three of the three reviewers determined that the advanced lipoprotein testing provided to the patient 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: All three reviewers are board certified in internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism, and all three are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for individual therapy sessions, twice a week for treatment of the patients condition. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested services. Nutt and colleagues state that psychotherapy is an integral part of patients treatment and should be considered for initial therapy for mild depression and as augmentation to an antidepressant for moderate or severe depression or for patients with adherence problems. Overall, psychotherapy has been shown to be effective for acute depression, particularly in combination with antidepressants, and can help in preventing depressive relapse and recurrence. APA Practice Guidelines recommend depression-focused psychotherapy to prevent a relapse of depression in the continuation phase. Leichsenring and colleague found evidence that individuals with chronic, complex mental illness seem to improve with long-term psychodynamic psychotherapy and that a greater number of sessions is associated with better outcome. Psychotherapy has been shown to help reduce patients symptoms, but like any other treatment, it needs to be continued for maintenance as major depressive disorder, like most medical conditions, is not curable but is at least manageable and treatable. In this case, the patient has an extensive history of depression and post-traumatic stress disorder, and she has had four inpatient psychiatric admissions so far this year. The patient was also noted to have recently presented with suicidal ideation. Under these circumstances, individual therapy sessions, twice per week, are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Nucynta. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees fibrous dysplasia and back pain. At issue in this case is whether the requested medication Nucynta is medically necessary for treatment of the enrollees medical condition.Nucynta (tapentadol) is an opiate agonist that is also a norepinephrine reuptake inhibitor. There is little published data to support the use of tapentadol in the tapering of pure agonist opiate therapy. The package insert speaks to a gradual reduction in the dose by 25 percent per step. Too rapid a taper can result in the opiate withdrawal syndrome. Opiate dose conversion calculators also give a wide range of equivalents, because of genetic factors, incomplete cross-tolerance and pharmacokinetics. Other pure agonist opiates have more supporting data that are on formulary as well as opioid withdrawal attenuation cocktails. Therefore, the requested medication is not medically necessary.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 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.