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 Humira 40 mg/0.8 mL, four times a month. Findings:  The physician reviewer found that  Current medical literature supports the continuation of Humira 40 mg weekly. In the ULTRA 1 trial, which was a high-quality randomized double-blind placebo-controlled trial, weekly use of Humira allowed an increase in maintenance of remission . In the ULTRA 2 trial, it was part of the protocol to change patients to weekly Humira if response was not adequate on Humira every two weeks . The trial advanced nonresponders at week eight to weekly therapy as well as week eight responders. Both groups contained a fraction that responded to dosing frequency increase. In the ULTRA 3 trial, weekly dosing of Humira was used for inadequate response or for flare . In a subset analysis of ULTRA 2 patients, those on weekly therapy had week-52 response rate of 25% after failing therapy given every 2 weeks . Changing to alternative therapy may result in loss of remission, disease flare, disease complications, and hospitalization.  For these reasons, continuation of Humira 40 mg/0.8 mL, four times a month is supported as medically necessary for treatment of 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 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 authorization and coverage for occipital nerve blocks for treatment of the enrollees headaches. Findings:  Two of the three physician reviewers found that there is sufficient support for the requested services in this clinical setting. This patients history is consistent with transformed migraine into chronic daily headache from pre-existing episodic migraine headache. This is often responsive to prophylactic medications. However, the patient has failed an exhaustive trial of these agents.  Bilateral greater occipital nerve blocks under the circumstance represents a reasonable and documented efficacious procedure. 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: Reviewers 1, 2, and 3 are board certified in neurology 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:Anenrollee has requested reimbursement for the prostate cancer antigen (PCA3) gene test.  Findings:  The physician reviewers found that The patientwho had an elevated prostate-specific antigen (PSA). The records noted that he underwent a biopsy of the prostate. He developed sepsis and required hospitalization. The patient did not want to have another biopsy performed.  The provider decided to do a prostate cancer antigen (PCA3) gene test instead of a biopsy.  The test returns with a value of 42.4. The patient has requested reimbursement for the PCA3 gene test performed The Health Plan denied reimbursement stating that PCA3 gene test was investigational for the evaluation of this patients medical condition. According to the medical literature, the indications for using PCA3 in diagnosing prostate cancer are not clear.  While this test has been used as an alternative to repeat biopsies of the prostate, its continued use to determine if a patient has cancer has come under scrutiny. The medical evidence is unclear as to its efficacy in detecting cancer in the prostate. In this patients case, the value of 42.4 on the test was suspicious for cancer. The value of the PCA3 reinforced the need for another biopsy.  While it is understandable that this patient would fear the same complications with another biopsy, there were precautions available to him.  In sum, this test had little value in determining whether he had cancer. Therefore, the PCA3 gene test performed  was not likely to have been more efficacious than the available standard modalities for the evaluation of this patients medical condition.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: All 3 Physician reviewers are board certified in urology and is actively practicing. The reviewers are an 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 the whole body skin photography provided.Findings:  The physician reviewers found that the use of whole body photography for monitoring nevi has not been demonstrated to improve the long-term outcome in patients with a history of melanoma in large clinical trials. In addition, the National Comprehensive Cancer Network (NCCN) does not recommend its use in this clinical setting. Thus, its usage is not considered to be standard of care in following an individual patients nevi. Accordingly, the whole body skin photography provided  was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service 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: Physician reviewers 1, 2, and 3 are board certified in dermatology 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 reimbursement for fabricated maxillary and mandibular interim prosthesis/stent provided. Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  The patient sustained facial trauma with loss of multiple teeth. Restoration of his teeth with dental implants was appropriate.  The interim prosthesis/stent was required in order to place and restore the dental implants.  The current evidence supports the fabricated maxillary and mandibular interim prosthesis/stent for the treatment of this patient.  All told, fabricated maxillary and mandibular interim prosthesis/stent provided was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in oral and maxillofacial 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested lumbar epidural steroid injection for treatment of his lumbar disc herniation with radiculopathy. Findings:  The physician reviewer found that the requested service is medically necessary for treatment of the patients medical condition. Researchers concluded that transforaminal epidural steroid injection was more often successful in patients without significant compression of the nerve root and, therefore, in whom an inflammatory basis for radicular pain is most likely. Researchers concluded that in a substantial proportion of patients with lumbar radicular pain caused by contained disc herniations, lumbar transforaminal injection of corticosteroids is effective in reducing pain, restoring function, reducing the need for other health care, and avoiding surgery. In this case, the patient has been under treatment for an L5-S1 disc herniation with nerve impingement. Conservative treatment has included two prior lumbar epidural steroid injections over the past 14 months with significant benefit. He presented with a significant flare-up of his right lower extremity radiculopathy following skiing. His symptoms of lumbar radiculopathy were consistent with reported known imaging evidence of disc herniation with S1 nerve root impingement. He reported significant functional difficulty in standing and walking that precluded his ability to work. Given the prior benefit to lumbar epidural steroid injection for the same condition and current significant symptoms and functional disability, a repeat transforaminal epidural steroid injection is supported by evidence based peer reviewed literature. Final Result: The reviewers 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: An enrollee has requested reimbursement for the substance abuse residential treatment center (RTC) services provided for treatment of the enrollees polysubstance abuse. Findings: The physician reviewer found that the records provided for review document that this patient showed no post-acute withdrawal symptoms. There was no evidence of danger to self or others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the RTC level of care. She was medically and psychiatrically stable. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with her care. She was motivated and was noted to be working the program. She was cooperative and participating in her treatment plan. No new problems had developed and there was no evidence that she was at imminent risk of relapse. She had no history of previous treatment at a lower level of care such as partial hospital program (PHP) or intensive outpatient program (IOP). She had emotional issues to be addressed. However, this did not require the structured environment of a RTC setting. She could have worked on these issues and her relapse prevention on an ambulatory level of care such as IOP. She did not meet the American Society of Addiction Medicine (ASAM) clinical guidelines for RTC level of care. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric consultation and bariatric surgery for treatment of the enrollees obesity. Findings: The physician reviewer found that there is a lack of published literature to support mandated preoperative weight loss efforts prior to bariatric surgery. In this case, the patient documents obesity with a BMI of 35 and sleep apnea. A bariatric consultation as well as a multidisciplinary team evaluation is clinically indicated as she is a potential candidate for bariatric surgery. This patient has previously failed both dietary and supervised efforts at weight loss without success. A bariatric team is best able to evaluate the candidacy of an obese patient. Although the patient is a potential candidate for bariatric surgery for treatment of obesity, it cannot be determined that bariatric surgery is medically necessary as she has not completed the bariatric consultation and multidisciplinary evaluation. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections for treatment of the enrollees Parkinsons disease. Findings: All three physician reviewers found that Botox has been used for many years for focal dystonia, cervical dystonia, blepharospasm, and spasticity. In addition, Botox has been shown to be well tolerated, and highly effective in dystonia in patients with Parkinsons disease. In a recent study, they concluded that, Botox injection significantly improved foot dystonia, pain and lower limb functional outcomes in patients with Parkinsons disease with deep brain stimulation. 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in neurology 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 reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patient presented with post-acute withdrawal symptoms. However, there was no evidence demonstrating that she was at risk to self or others. She was medically and psychiatrically stable. She demonstrated impulsivity with a recent history of detoxification and immediately relapsing.  This was compounded by the fact that she had recently undergone a double mastectomy due to breast cancer, causing additional depression, anxiety, and stress. In this clinical setting, the risk for relapse is increased and residential treatment was medically necessary. At the beginning of treatment she was isolative, however she became more motivated and engaged. She was described as attentive, engaged and actively sharing. She could have been stepped down to a lower level of care. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx melanoma assay gene testing for evaluation of the enrollees cutaneous melanoma. Findings:  Two of the three physician reviewers found that this patient presented with a melanoma with a Breslow depth of 2.3 mm. This places him into at least stage 2 disease. In stage 2 disease, the American Joint Committee on Cancer (AJCC) and National Cancer Guidelines dictate certain protocols for further diagnosis, staging and prognosis as well as treatment paradigms. The DecisionDx melanoma assay results would not change the staging, guidelines or care of this patient based on these guidelines. The DecisionDx testing has shown some accuracy in predicting which stage 1 patients might be at risk for metastasis but at this time what to do with the information has not been scientifically elucidated. This patients care would not change based on the testing 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anesthesia service provided during a colonoscopy performed for evaluation of the enrollees risk for colon cancer. Findings: The physician reviewer found that the patient has an ASA preoperative physical status classification score of 1. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the research given a low preoperative physical status classification score. Final Result: The reviewer determined that the service 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 anesthesiology 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: The parent of an enrollee has requested authorization and coverage for 27 hours per week of one-on-one applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that according to a study  Ample research has shown that intensive applied behavior analysis (ABA) treatment produces robust outcomes for individuals with autism spectrum disorder (ASD). This research studied 726 children (ages 1.5 to 12) to evaluate the relationship between treatment intensity and treatment outcomes. The study showed a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In addition, several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes . In this case, the patient has made progress in many areas, but he continues to demonstrate significant delays in adaptive skillsets, tantrums with self-injury as well as spitting and smearing of saliva. The patient has recently demonstrated a significant increase in tantrums and self-injury behaviors. Based on the documentation submitted for review, the request for 27 hours per week of one-on-one ABA therapy is medically necessary for treatment of the patients autism spectrum disorder.  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: Physician reviewer number two 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 reimbursement for the tumor necrosis factor (TNF) antagonist blood test for evaluation of the enrollees Crohns disease.  Findings: Three physician reviewers found that TNF antagonist blood test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab (IFX) or the presence of IFX antibodies have an adverse effect on the clinical outcome of a patients response to treatment. While there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. 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 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.