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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for fertility preservation services (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) for treatment of the enrollees risk of iatrogenic infertility due to treatment for breast cancer. Findings:  The physician reviewer found that Successful cancer treatment in younger patients often leads to reduced fertility. If the cancer treatment can be delayed, it is possible to undergo ovarian stimulation and retrieve and freeze eggs (both mature and immature) or produce embryos that can be frozen for later transfer to the individual or a gestational carrier. The American Society for Reproductive Medicine (ASRM) indicates that the established strategy for preservation of female fertility is for a woman to undergo a cycle of in vitro fertilization (IVF) and create embryos for later use. The ASRM also noted that the established methods of fertility preservation include sperm cryopreservation in men and embryo and oocyte cryopreservation in women. Patients with breast cancer undergoing initial treatment with lumpectomy or mastectomy often will have an interval of time available to them for an oocyte retrieval prior to initiating postoperative chemotherapy. Oocyte and embryo preservation are therefore considered a standard of care for fertility preservation in patients about to undergo breast cancer treatments. Given this support, the requested fertility preservation services (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) was and is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were and 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. In this case, the patient sustained a right hamstring injury playing tennis in 2016. The patient failed to improve with extension physical training, medications, ice, and platelet-rich plasma injections. The patient had reportedly plateaued at 50% of normal performance level. Clinical examination findings were consistent with evidence of high-grade partial tearing of the right hamstrings with retraction of the lateral fibers. The patient underwent right proximal hamstring repair, right amniopatch allograft patch, and sciatic neurolysis. There is no evidence that the surgery performed was emergent, as the patients injury had been present for six months and findings of hamstring tearing were documented three months prior to surgery. Therefore, the services provided are not considered emergency medical services. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. 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: The patient has requested authorization and coverage for L5 and S1 decompression and fusion treatment of the enrollees lumbar spondylosis with bilateral foraminal stenosis at L5-S1 with bilateral radiculopathy. Findings:  The physician reviewer found that in the peer-reviewed medical literature, researchers noted that lumbar fusion is a commonly performed procedure for the treatment of painful instability of the spine, usually manifest as chronic low back pain. This patients medical records do not include evidence of instability, fracture, or tumor. In addition, there is no significant neurologic deficit on physical examination to support an indication for lumbar fusion or lumbar decompression. Final Result: The reviewer determined that the requested surgery 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 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 patient has requested reimbursement for the gene testing panel performed .Findings:  The physician reviewer found that current evidence does not support the use of genotyping when choosing a neuropsychiatric medication and even less is understood about its use in the treatment of anxiety disorders. In this patients case, genetic testing was requested following failure of at least one neuropsychiatric medication. However, the medical records do not include documentation of the patients symptoms, medications and dosages attempted, length of treatment, augmentation strategies, side effects experienced, or participation in psychotherapy. It is also unknown if she had comorbid medical conditions, which may affect drug metabolism. The testing includes charts which show specific medications under the categories of antidepressants, anxiolytics, and stimulants. The charts provided showed the different transfer system gene results, therapeutic implications, and clinical impact. The fact that any one of these results shows up on genetic testing has not been shown in the medical literature to be more or less effective than another. All told, the gene testing panel was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three 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: Physician reviewer 1, 2 & 3 are board certified in psychiatry 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 two weeks prescription of tramadol hydrochloride (HCL) 50 mg tablet per month. Findings:  The physician reviewer found that in the documentation available for review, the stepwise World Health Organization (WHO) ladder for pain relief is considered a reasonable approach to pain control in the palliative and the non-palliative settings. In this patients case, not all non-opioid treatment options have been utilized. The medical literature suggests that clinicians should consider alternative options to opioids as well as to wean patients to lower doses of opioids or even off opioids for treatment of pain. Furthermore, no objective treatment goals for pain and function are noted for the requested medication. The Centers for Disease Control and Prevention states that when starting opioid therapy, clinicians should prescribe the lowest effective dosage. In addition, multiple minimal requirements for opioid prescribing have not been performed and the need to use them as the primary medication treatment strategy for pain has not been established in this patients case. For all these reasons, the requested medication, two weeks prescription of tramadol HCL 50 mg tablet per month, is not medically necessary for 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the wound therapy pump vacuum and wound dressing sets/equipment. Findings:  The physician reviewer found that in the medical literature, a study noted that negative pressure wound therapy (NPWT) following greater saphenous vein (GSV) harvest is safe, well tolerated and improves postoperative recovery with prolonged impact on mobility at six weeks. Another study reported that the VAC can effectively reduce postoperative complications, such as lymphedema, incision infection, wound dehiscence, and skin flap necrosis in CABG patients who underwent great saphenous veins harvesting. Overall, there is adequate data in the scientific data supporting NPWT for surgical dehiscence. For these reasons, the wound therapy pump vacuum and wound dressing sets/equipment were 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 equipment at issue was 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 reviewer number one is board certified in family practice 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.Physician reviewer number two is board certified in surgery with sub-specialty certification in vascular 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.Physician reviewer number three 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI) with contrast for evaluation of the enrollees dense breast tissue. Findings:  The physician reviewer found that the records in this case indicate that the mammogram including tomosynthesis and spot compression films continue to be concerning. Moreover, biopsy of the suspicious area is not possible since the area cannot be triangulated for accurate localization. The negative ultrasound is reassuring, but does not confirm that the area of mammographic concern has been examined since it is visible on only one plane. In this patient, further evaluation is indicated in light of the change in the mammographic findings, the dense breast tissue, and the positive family history of breast cancer. Magnetic resonance imaging (MRI) is the procedure of choice for problem solving in this type of patient. A negative MRI would be of great assurance that imaging surveillance is indicated while a positive study would allow the adequate triangulation of the suspicious area for tissue sampling. All told, the records provided for review demonstrate that the requested bilateral breast MRI with contrast is medically necessary for further evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: The patient has requested reimbursement for the Rituxan 375 mg/m2 once per week for four weeks for treatment of the enrollees chronic inflammatory demyelinating polyneuropathy (CIDP). Findings:  Two physician reviewers found that this is patient with chronic inflammatory demyelinating polyneuropathy (CIDP) with progressive functional decline on standard therapies including intravenous immunoglobulin (IVIG) and prednisone. Despite standard medical management, the patient has progressed to a walker, had developed additional knee weakness, and has had several near falls. The patient is also at risk of significant side effects from the use of his high dose prednisone and IVIG. While Rituxan is not recommended for all patients with CIDP, it has been shown to be beneficial in select groups of patients. Undertreated CIDP can lead to rapidly worsening functional status and potentially severe injury due to fall. In addition, the long-term use of prednisone can lead to cataracts, osteopenia, hypertension and other untoward side effects. To this end, it is reasonable to treat this patient with Rituxan given the provided documentation. For these reasons, the requested Rituxan 375 mg/m2 once per week for four weeks is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in neurology with sub-specialty certification in pain medicine 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 orthotics for treatment of the enrollees foot pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of orthotics. In this case, the patient has collapsed arch, pain upon ambulation, neuropathy, a significant hypermobility syndrome and Ehlers-Danlos syndrome. Custom orthotics have been demonstrated to be effective in the treatment of the above mentioned pathologies. Custom orthotics are firm functional devices that support both the medial arch as well as the midtarsal arch, and will reduce hypermobility, support the foot and slow if not halt further progression of patients foot deformity. Reducing hypermobility in the foot will likely help alleviate the patients foot pain. As such, the request for orthotics is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 podiatry 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 patient has requested authorization and coverage for Epclusa with ribavirin (RBV) 1000 mg for 24 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1b. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines specifically recommend treatment of patients with decompensated cirrhosis. The guidelines recommend that genotype 1b patients with decompensated cirrhosis who have failed an nonstructural protein 5A (NS5A) inhibitor such as Harvoni should be re-treated with Epclusa and RBV for 24 weeks, based on successful treatment in decompensated cirrhosis in the ASTRAL-4 trial, and the 97% success rate of Epclusa with RBV for 24 weeks in genotype 1b patients after NS5A inhibitor failure in a separate study. Final Result: The reviewer determined that the requested regimen 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucala 100 mg. Findings:  The physician reviewer found that in the peer-reviewed medical literature, a study reported that Nucala has not been demonstrated to improve health outcomes in patients with any eosinophil related disorder. Currently, Nucala is the subject of a phase 3 study. Standard therapies for treatment of this patients medical condition include Hydrea and vincristine. Overall, there is a lack of data supporting the safety and effectiveness of Nucala in this clinical setting. Thus, the requested Nucala 100 mg is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three the reviewers determined that the requested medication is 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 2 of the 3 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are  actively practicing.  And one physician reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for myocardial perfusion stress imaging (nuclear test) for evaluation of the enrollees palpitations. Findings:  The physician reviewer found that based on the records provided the patient presents with no documented coronary risk, atypical chest symptoms at rest, a normal cardiovascular physical examination, no documented electrocardiogram and reference to a normal echocardiogram. In this circumstance the pretest likelihood that the patients symptoms represent coronary ischemia is low, and if additional evaluation is indicated then routine treadmill electrocardiography would be sufficient and medically appropriate. In addition, there is no documentation demonstrating the patients inability to adequately ambulate on a treadmill and there is no documented baseline electrocardiographic abnormality that would reduce the interpretation accuracy of treadmill electrocardiography. Moreover, current guidelines endorsed by several national organizations also do not consider nuclear stress testing appropriate in this setting. Final Result: The reviewer determined that the requested testing is 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 internal medicine with sub-specialty certification in cardiovascular 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.