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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton radiation therapy for treatment of the enrollees anal cancer. Findings:  The physician reviewer found that based on review of available data, the services at issue were not medically necessary for the treatment of the patients anal carcinoma. There is very limited clinical studies comparing proton therapy to photon intensity modulated radiation therapy (IMRT) for anal cancer. Additionally, there are a few studies on proton therapy for rectal cancer, but rectal cancer is not the same entity as anal cancer as the treatment approach and radiation fields differ significantly. One existing clinical data on anal cancer is a Japanese case study where a single patient with distant metastases had their primary anal cancer site treated with protons. Per researchers, the authors note the following, anorectal  cancer  offers  an  open  arena  to  explore  clinical  outcomes  and  toxicities  to  back  up  dosimetric superiority data. Based on the available data, proton radiation therapy was not medically necessary for the treatment of this patients anal cancer. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) care for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. Note there was limited documentation from an attending psychiatrist at the RTC. The patient was at mild risk of harm (score 2) as the documentation states the patient did not have a history of suicide attempts, persistent suicidal ideation, psychosis, mania, paranoia, or delusions. The patient demonstrated mild functional impairment (score 2) as the provider reported the patient shows only slight difficulty in relational and/or work/school functioning. The patient has a co-morbidities (score 2) including oppositional defiant disorder, unspecified anxiety disorder, and parent-child relational problem. However, the patient does not have any medical problems which require 24-hour monitoring. The patients recovery environment is mildly stressful (score 2) as he was noted to have a mild problem interacting with others. The patients recovery environment is supportive (score 2) and the patient demonstrated significant response to treatment (score 2) in terms of resiliency. The provider noted that the patient responded well to RTC level of care and had improved. Overall, the patient was cooperative, constructive, and participates well in groups (score 2). This gives the patient a composite score of 14, which is consistent with routine outpatient care. Thus, the patient is a candidate for treatment in a less restrictive environment. The patient has made improvements in the RTC treatment and continues to need treatment for his oppositional defiant disorder, unspecified anxiety disorder, and parent-child relational problem, but this can be accomplished at a less restrictive environment. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with expertise in child and adolescent 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 patient has requested reimbursement for the residential treatment services provided Findings:  The physician reviewer found that the records provided for review indicate that this patients post-acute withdrawal symptoms were mild to moderate and could have been managed symptomatically as an outpatient. He was not a danger to himself, and he was not aggressive or self-injurious. There were no emotional, behavioral, or cognitive issues that would have required residential services. He was not manic, psychotic, or agitated. He was medically and psychiatrically stable. He did not show signs or symptoms of bipolar disorder. He attended and participated in all forms of treatments provided. He has a past history of multiple substance abuse treatments at different levels of care, therefore the process and AA program are familiar to him. He was aware of the consequences that his substance use had on his relationships, employment, and education. He recognized his triggers and demonstrated that he was capable of sustaining a prolonged period of sobriety. He had not undergone a lower level of care within the prior year. Although relapse risk was present, this patient could have been treated outside of the restrictive 24-hour residential environment, and entered treatment in an ambulatory setting such as an intensive outpatient program (IOP). In conjunction with this, he could have concurrently attended AA, worked with a sponsor, and found other community support groups. All told, the residential treatment services were not medically necessary for treatment of the patients medical condition.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 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 authorization and coverage for Arthrotec 75/200 (diclofenac 75 mg and misoprostol 200 mg) Findings:  The physician reviewer found that : the request for Arthrotec 75/200 (diclofenac 75 mg and misoprostol 200 mg) is not medically necessary for treatment of the patients medical condition. Misoprostol is a synthetic prostaglandin that is used to reduce the risk of stomach ulcers in patients treated with nonsteroidal anti-inflammatory drugs (NSAIDs). In this case, the patient does not have a diagnosis of gastroesophageal reflux disease, gastric ulcers or intolerance of a nonselective NSAID medication. Lastly, Arthrotec is a compound drug that includes convenience packaging of more than one medication. For these reasons, the request for Arthrotec has not been established as medically necessary for the treatment of the patients medical condition.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 physical medicine and rehabilitation with sub-specialty 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy 25 mg one tablet daily for the duration of one year for treatment of the enrollees hepatitis B virus. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. For this reason, the request for Vemlidy 25 mg one tablet daily for the duration of one year is medically necessary for the treatment of the patients chronic hepatitis B.  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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene panel testing for evaluation of the enrollees astrocytoma. Findings:  Two physician reviewers found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Li-Fraumeni syndrome is an inherited autosomal dominant disorder that is manifested by a wide range of malignancies that appear at an unusually early age. Li-Fraumeni syndrome is also known as the sarcoma, breast, leukemia, and adrenal gland (SBLA) cancer syndrome. This cancer predisposition syndrome is inherited as an autosomal dominant disorder and is associated with abnormalities in the tumor protein p53 gene (TP53). Several case reports have suggested that radiation-induced cancers are more common in patients with Li-Fraumeni syndrome and preclinical studies have provided additional evidence in support of this relationship. Thus, radiation therapy is generally avoided as a component in the management of these patients whenever possible. The differential diagnosis includes other inherited cancer syndromes in patients whose presentation suggests Li-Fraumeni syndrome such as BRCA1 and 2 mutations and Lynch syndrome (there are a number of genes involved in the repair of DNA mismatch errors, including M1H1, MSH2, MSH6, PMS1, and PMS2). The recent introduction of multi-gene testing for hereditary forms of cancer has rapidly altered the clinical approach to testing at-risk patients and their families. Based on next-generation sequencing technology, these tests simultaneously analyze a set of genes that are associated with a specific family cancer phenotype or multiple phenotypes. When more than one gene can explain an inherited cancer syndrome, then multi-gene testing may be indicated. As such, multi-gene panel testing was clinically indicated for this patient. Final Result: The reviewers determined that the testing at issue was 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 65 gram intravenous immunoglobulin (over eight hours) two times daily. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient is postulated to have an adult form of PANDAS.  Per the medical literature, the syndrome would be unlikely to occur in adults. The U.S. Food and Drug Administration approved indications for intravenous immunoglobulin do not include treatment of this syndrome. A randomized controlled trial by Williams and colleagues of immunoglobulin in children with this syndrome demonstrated no benefit from this therapy. In this patients case, there is a lack of evidence of a recent streptococcal infection. She has other diagnoses that explain her reported symptoms. All told, the requested 65 gram intravenous immunoglobulin (over eight hours) two times daily 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 with sub-specialty certification in infectious 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for genicular nerve block and radiofrequency ablation for treatment of the enrollees right knee osteoarthritis. Findings:  Three physician reviewers found that in the peer-reviewed medical literature, researchers reported that there is a need for further high quality randomized controlled trials with larger patient samples evaluating the use of radiofrequency denervation of the spinal zygapophyseal joints for musculoskeletal pain disorders. In this patient, radiofrequency ablation specifically referencing the superior lateral genicular nerve, the superior medial genicular nerve and the inferior medial genicular nerve will not address the documented problems of joint surfacing changes, malalignment with varus deformity, and likely intraarticular changes to menisci within the patients knee joint. Given the lack of support, the requested genicular nerve block and radiofrequency ablation are not likely to be more beneficial than standard treatment interventions for treatment of this patients right knee osteoarthritis. 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 are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total hip arthroplasty in the right hip for treatment of the enrollees chronic hip pain. Findings:  The physician reviewer found that Evidence based medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. Criteria includes exercise therapy (supervised physical therapy and/or home rehab exercises) and medications. Subjective findings should include limited range of motion, or nighttime joint pain, or no pain relief with conservative care. Objective findings should include over 50 years of age and body mass index less than 35. Imaging findings of osteoarthritis on standing x-rays or arthroscopy are required. Guidelines state that every effort should be made to avoid a hip replacement in younger patients. The National Institute for Health and Care Excellence recommend total hip arthroplasty and resurfacing arthroplasty as treatment options for patients with end stage arthritis of the hip who have failed nonsurgical management.  The American College of Rheumatology recommends total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. Medical therapy recommendations included exercise, weight loss for overweight patients, medication management, walking aids, and psychosocial interventions. This patient has a three year history of chronic right hip pain that interferes with activities of daily living and sleep. Clinical examination findings are consistent with impingement syndrome, including positive FADIR testing and radiographic findings of crossover sign. Right hip x-ray report documented a normal study with no significant bony or joint pathology. The orthopedic surgeon has reported findings consistent with moderate hip osteoarthritis. Conservative treatment was documented to include anti-inflammatory medications, platelet rich plasma injections, physical therapy, activity modification, and corticosteroid injections without sustained improvement. However, evidence based peer reviewed criteria have not been met at this time. There is a lack of evidence of severe osteoarthritis to support total hip arthroplasty in a patient under the age of 50. Additionally, there is no discussion of alternative surgical treatment options for this patient or evidence of a trial of reasonable use of an assistive device/walking aid(s). 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 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 magnetic resonance imaging. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Per the records, the patient has no history of trauma, malignancy or abnormal neurological examination to provide an indication for MRI of the lumbar spine at this time. There are no red flags to warrant MRI of the lumbar spine prior to a conservative trial of therapy, including physical therapy for six weeks, prior to advance imaging.  The current medical evidence does not support the requested services in this clinical setting. All told, the requested MRI is not medically necessary for the 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 diagnostic 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Foundation One gene testing for evaluation of the enrollees non-small cell lung cancer. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion. For the treatment of patients with advanced non-small cell lung cancer, broad molecular profiling, such as with Foundation One testing, is considered a standard of care. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: 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.