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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for selective internal radiotherapy (SIRT) using Yttrium-90 radioembolization therapy. Patients with breast cancer with liver metastases are candidates for treatment with radioembolization, which has been shown to improve patient health outcomes. The current peer-reviewed literature suggests that radioembolization may be associated with a greater response than chemotherapy in this clinical setting. Further, guidelines endorse the use of radioembolization therapy for treatment of this patients breast cancer with liver metastases . The medical records indicate this patient does not have any documented contraindication to the requested treatment. All told, SIRT using Yttrium-90 radioembolization spheres is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy is considered likely to be more beneficial than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is requesting Tremfya injections. Findings:  The physician reviewer found that there is no documented contraindication to the use of formulary alternatives such as Humira, Enbrel or Cosentyx. Therefore, Tremfya100 injections are not medically necessary for the patient. The Health Plan has denied the requested medication as the Health Plan has approved formulary alternatives, Humira, Enbrel and Cosentyx. At issue in this case is whether Tremfya injections are medically necessary for treatment of the patients medical condition. According to the American Academy of Dermatology and the National Psoriasis Foundation, formulary alternative medications such as Humira, Enbrel and Cosentyx, are safe and effective for the treatment of psoriasis (Menter, et al.). An analysis of Enbrel showed that at week 12, patients receiving Enbrel, achieved a 75% improvement on the psoriasis area severity index (PASI) compared with those receiving placebo. Analysis of Humira showed that at week 40, the rates of achievement of PASI 75 and PASI 90 among patients treated with Humira were 67% and 40%, respectively. Analysis of Cosentyx versus placebo showed that the percentage of patients who achieved PASI 75 at week 12 was higher with each Cosentyx dose than with placebo. This patient has failed treatment with Stelara. However, there is no documented contraindication to the use of formulary alternatives such as Humira, Enbrel or Cosentyx. Therefore, Tremfya100 mg/mL injections 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 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:  The enrollee has a history of asthma and is requesting the medication, Symbicort inhaler. Symbicort, is a combined inhaled corticosteroid and a long acting beta-2-agonist. However, other available medications include combination inhaled corticosteroid and a long acting beta-2-agonist (Advair, generic Advair  fluconisol/salmeterol, and Trelegy). There is no convincing or objective evidence in the submitted documents that the enrollee has contraindication to, or a potential drug interaction with other formulary alternatives (Advair, Fluticasone, and salmeterol). There are no  adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long term efficacy and safety of Symbicort over the preferred formulary medications for the treatment of this patient medical condition.  Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the enrollees condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in Pulmonary 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:  The enrollee has requested coverage for residential treatment services that was denied by the health plan as not medically necessary. The records indicate this enrollee was admitted for inpatient mental health residential treatment due to worsened depressive symptoms and alcohol use.  He had depressed mood, suicidal ideation with a plan to overdose, feelings of hopelessness, helplessness and decreased energy. He relapsed prior to admission after reporting being sober for one year. Past medical history included delirium tremens and a past psychiatric hospitalization.  Medications included Lexapro and Campral.  He had diagnoses of Major Depressive Disorder and Alcohol Use Disorder.  While admitted, he was placed on self-harm and suicide precautions, received a medication evaluation, as well as individual and group therapy. Medical guidelines indicate that patients should be treated in the least restrictive setting that is most likely to prove to be safe and effective and that patients with suicidal plans, intent, behaviors or inability to adequately care for basic needs are in need of inpatient treatment. The estimated degree of risk to self and to others is a significant factor in determining treatment setting. In this case, on the days in question, there were no reports of suicidal or homicidal ideations, plan or intent, self-injurious, aggressive or agitated behavior, psychotic symptoms, inability to adequately care for self, medical instability or substance use. The patients mood had improved and there were no reports of severe depressive symptoms or manic episodes.  There were also no reports of identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour mental health residential setting or that could not be achieved in a less restrictive setting. Final Result: The reviewer determined that the requested service is not medically necessary for thetreatment of the enrollees medical condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested authorization and coverage for Nutropin AQ Nuspin for the treatment of Short Stature. Findings:The physician reviewer found that baseline profiles and a bone age x-ray were considerably delayed by years vs. chronological age.  At the then current height, the final adult height estimate was far greater than the mid parental target height; actually, over 2 standard deviations above the genetic mean. The baseline labs were all normal including thyroid tests and the IGF-1 level was approximately the mean for age/gender.  Given the reassuring final height estimate, no therapeutic interventions were initiated at the time.  The enrollee was seen again and demonstrated sub-optimal interval height velocity with height deceleration.  A repeat set of labs confirmed the normal IGF-1. At this time the decision was made to start growth hormone therapy and the enrollee did well, without adverse effects with the therapy.  There are notes indicating treatment was provided for years.  As per the medical literature, Idiopathic Short Stature is an FDA defined condition where the child is below the 1st percentile and evidence at the time of treatment suggests an adult height below the first percentile.  Data in this case does not document that this criterion is met. The patients starting height was not below the 1st percentile and his bone age predicted a very normal adult height. The requested treatment with Nutropin AQ Nuspin was not appropriate.    Final Result: The reviewer determined that the service at issue is not medically necessary for treatment of the patients condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in Pediatric Endocrinology and is actively practicing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested authorization for Nutropin AQ Nuspin for the treatment of Short Stature. Findings:The physician reviewer found that a review of the records indicates the patient was initially seen for concern about familial short stature.  Bone age was delayed vs. chronological age.  The final adult height estimate was over the mid parental target height. The baseline labs were all normal including thyroid tests. No therapeutic interventions were initiated at that time. On a return visit, the patient demonstrated sub-optimal interval height velocity with height deceleration. Growth hormone therapy was started at that time. Sub-optimal interval height velocity on the current dosage of growth hormone persisted despite a dosage increase. The patient has a diagnosis of Idiopathic Short Stature, which is a Food and Drug Administration (FDA) approved diagnosis for growth hormone. However, the approval criteria include a predicted adult height below the 1st percentile. To meet the predicted adult height criteria, the patients predicted height must be below 160cm (63 inches), as the patient is a male. The growth curve documents poor growth and bone age delayed.  However, the patients predicted height does not meet the criteria for approval of growth hormone treatment. The requested treatment with Nutropin AQ Nuspin is not appropriate.Final Result: The reviewer determined that the service at issue is not medically necessary for treatment of the patients condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in Pediatric Endocrinology and is actively practicing.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement and prospective authorization and coverage for intravenous immune globulin (Gammagard received on 12/13/18 and Gamunex received on 9/05/18, 1/17/19, 2/27/19, and going forward). The Health Plan has denied the services at issue as investigational for treatment of the enrollees hypogammaglobulinemia.Findings:  Two out of three physician reviewers found that the use of vaccine responses as a diagnostic tool is firmly established for the evaluation of patients undergoing immunologic evaluation. Vaccine responses are frequently used in the context of providing a diagnosis or for justifying a particular therapeutic intervention. In the absence of more direct evidence, the clinical status of the patient must dictate the therapeutic intervention and not the response or lack of response to a particular vaccination. Immunoglobulin therapy is essential and clinically useful for a broad array of diagnoses. Given the limited nature of this therapeutic agent, careful consideration of particular clinical indications is of the essence. In this case, the patient does not meet criteria for immunodeficiency with immunoglobulin replacement therapy. Although he has low pneumococcal titers, it is unknown when his vaccination was received as antibody titers need to be checked no greater than four to six weeks after vaccination in order to assess responsiveness. In addition, a trial of re-vaccination was not reportedly attempted. In addition, his IgG, IgM, and IgA values were normal before beginning IVIG. One physician reviewer found that the patient and his treating provider report significant clinical improvement with IgG replacement, with fewer, milder respiratory infections. Given his history of low IgG and recurrent sinopulmonary infections, plus response to treatment, IVIG treatment has been beneficial.Final Result: The reviewers determined that the services at issue were not and 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 reviewer #1 is board certified in internal medicine and allergy and immunology, #2  is board certified in allergy and  immunology and internal medicine with subspecialty certification in rheumatology and #3 is board certified in allergy and  immunology and all 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: The patient has requested authorization and coverage for Emgality syringe injections 120 mg/mL. Findings:  Two of the three physician reviewers found that Emgality has been U.S. Food and Drug Administration (FDA) approved for the treatment of migraine headaches. In addition, there is medical evidence that Emgality has a beneficial effect for patients with cluster headache as well. In this case, the patient experienced intractable cluster headaches that were resistant to several different drug classes. Furthermore, the patient had a documented successful trial of Emgality, which reduced the headache frequency by half. Given these findings, the continued use of Emgality syringe injections 120 mg/mL is 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 requested medication is 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 sleep medicine and is actively practicing. One Reviewer is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing. One Reviewer is board certified in neurology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Euflexxa injections in both knees. The Health Plan has denied the request as not medically necessary.Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.A review of current literature pertaining to viscosupplementation reveals mixed results. Research studies found that intra-articular hyaluronic acid (HA) injections provide a moderate symptomatic benefit to knee osteoarthritis without major safety concerns. Researchers performed a meta-analysis of double-blinded, sham-controlled trials with at least 60 enrollees and concluded that the evidence did not show clinically important differences of HA over placebo. Researchers concluded that viscosupplementation increased functional scores in enrollees with severe osteoarthritis of the knee, especially within three months of injection. However, it was not superior to triamcinolone. In light of the foregoing, 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 prior injections, and the options are limited, with the alternative being bilateral total knee arthroplasties. As such, the request for Euflexxa injections in both knees are medically necessary for treatment of this enrollees knee osteoarthritis.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the enrollees 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for the right knee.Findings:  Two of the three physician reviewers found that the submitted documentation supports the requested services in this patients case. The records document a history of diabetes and mild to moderate osteoarthritis of the right knee. This patient has failed to respond to various conservative treatments, including nonsteroidal anti-inflammatory drugs and corticosteroid injections. An exhaustive review of the current medical literature pertaining to the viscosupplementation reveals mixed results. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence is limited. As such, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. This patient has limited treatment options. Orthovisc injections are medically appropriate in this clinical setting. Therefore, the requested Orthovisc injections for the right knee are 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 30 chiropractic treatment visits. After careful review of the current evidence-based practice guidelines, the request for 30 chiropractic treatments visits for maintenance care is not supported by the medical records provided for review. In this patients clinical setting, the International Chiropractic Association (ICA) recommends 12 chiropractic visits, over six to eight weeks, to achieve improvement. The records provided for review document that this patient has been treated with medications, physical therapy, chiropractic care, and home exercise. The provider noted the patient experienced relief of symptoms with previous chiropractic treatment in four to eight visits. Given these findings, 12 chiropractic visits are medically necessary for management of this patients chronic neck and upper back pain.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 a board certified chiropractor 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 RT300 functional electrical stimulation (FES) cycle therapy system.Findings:  Two out of three physician reviewers found that there is sufficient support for the requested device in this patients case. Once a patient has sustained a spinal cord injury and is stabilized, lower extremity mobilization can be achieved by use of an ergometer powered by a patients own muscle strength evoked by functional electrical stimulation (FES). Electrical stimulation of the peripheral and central nervous system is commonly used for rehabilitation and management of complications following spinal cord injury. Electrical stimulation may improve the functional status and quality of life of individuals with spinal cord injuries. The medical evidence indicates that the benefits of FES ergometry include increases in lean body mass with a decrease in whole body fat content, increases in muscle endurance, increases in muscle output, improved oxygen uptake, positive changes in spasticity and increases in joint range of motion. Thus, the requested RT300 FES cycle therapy system is likely to be superior over other treatment options.Final Result: The reviewers determined that the requested device is 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 physical medicine and rehabilitation 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.