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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan. Findings:  Three physician reviewers found in patients with oligometastatic uterine cancer, there is risk of failure of local cancer control as well as metastases to multiple distant anatomic sites, not simply abdomen and pelvis. The physiologic tagging offered by PET is of high value in these patients. Physiologic tagging serves as a differentiating tool between post treatment fibrosis and persistent local tumor. Patients with oligometastatic cancer may have tumors at different and unexpected distant sites, such as the chest, scalp and axillary nodes.  It is important to identify these potential distant sites. Therefore, the requested PET scan is likely to be more efficacious than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2 and 3 are board certified in diagnostic radiology 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Epclusa 400-100mg, for 12 weeks. The submitted documentation supports the medical necessity of the requested medication. 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 nonliver-related conditions. In this case, the submitted medical records support that the patient has a positive diagnosis of hepatitis C, and the therapy recommended by the provider is one of four that is scored as a 1A recommendation by the AASLD/IDSA guidelines. Accordingly, Epclusa 400-100mg, for 12 weeks, is medically necessary for treatment of the patients medical condition.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 a subspecialty 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for Endoscopic Retrograde Cholangiopancreatography (ERCP). The submitted documentation does not support the medical necessity of the requested services. The patient was appropriately treated for the finding of pancreatic duct stone with extracorporeal shockwave lithotripsy (ESWL). Repeat endoscopic retrograde cholangiopancreatography (ERCP) may not be of benefit in the long term beyond ESWL alone. There was no finding of a pancreatic duct stricture requiring endoscopic therapy. Ee-intervention is not always required for recurrent stones. Additionally, because ERCP is associated with risks, including pancreatitis, less invasive modalities such as endoscopic ultrasound can be used to identify stones rather than ERCP. ERCP can be reserved to intervene if known stones are present. In this case, it is not clear that stones are present in the pancreatic duct, and stones were not found on recent ERCPs. In addition, the ERCP is associated with procedural risks. Under these circumstances, ERCP is not is medically necessary to treat the patients medical condition at this time.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 internal medicine, with subspecialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Xenical (orlistat capsule 120 mg). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees obesity. At issue in this case is whether the requested medication Xenical (orlistat capsule 120mg) is medically necessary for treatment of the enrollees medical condition.According to the FDA, Xenical is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia). The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention: a combination of diet, exercise, and behavioral modification. All patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with a BMI greater than 30kg/m or a BMI of 27-29.9 kg/m with comorbidities, such as hypertension or diabetes mellitus, has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy is suggested. After started treatment with a weight loss medication such as Xenical, the patient should be monitored for weight loss, blood pressure, and heart rate on a weekly basis for four weeks and then monthly for the next three to four months. If patients do not lose 4 to 5 percent of body weight after 12 weeks of tolerated maximum-dose therapy, the drug should be tapered and discontinued. In this case, the documentation does support that the patient has been treated with Xenical for obesity. He has lost between 4-5% of his body weight after six months of therapy. Furthermore, the clinic has changed the type of scales and this may give inaccurate measurements of weight. It is medically reasonable to continue Xenical for further weight loss, therefore the request for the medication is considered medically necessary.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 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 foot orthotics. The Health Plan has denied this request indicating that the requested devices are not medically necessary for treatment of the enrollees bilateral foot pain.At issue in this case is whether the requested foot orthotics are medically necessary for treatment of the enrollees medical condition.After careful review of the enclosed information and pertinent guidelines for this case, the custom molded orthotics are medically necessary for this patient. It is well documented that this patient suffers with a painful Mortons neuroma of bilateral feet. The medical necessity definition requires that the patient be treated for a malformed body member within the normal guidelines of current medical thinking. In this particular case, the patients physician would like them to be casted for custom functional orthotics. The biomechanical support that an orthotic gives to a patients foot along with an added metatarsal and or neuroma pad to the orthotic alleviates stress, strain, and pressure to the metatarsal heads and neuroma area. Therefore, the recommended orthotics are medically necessary for this patient.Final Result: The reviewer determined that the requested devices 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for the medication Lyrica . The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.Lyrica is not indicated for rheumatoid arthritis (RA) or other autoimmune diseases. An article noted the options for patients with inflammatory arthritis and fibromyalgia and found no randomized trials that support the use of Lyrica; rather its use is empiric and not evidence based for RA with widespread muscle pain. The requested medication is not medically reasonable or necessary.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vedolizumab (Entyvio) injections. Current American College of Gastroenterology Clinical Guidelines for the management of Crohn's disease support the use of vedolizumab prior to alternatives. In this case, the patient has diagnosed pouchitis and Crohns disease, and he has had an inadequate response to standard therapies. There is also a reasonable concern that anti-TNF medications would be more likely to cause immune suppression and put the patient at risk for serious infection. Under these circumstances, vedolizumab (Entyvio) injections are medically necessary for treatment of the patients medical condition.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 subspecialty 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.Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pneumatic compression garment. Findings:  Two of the three physician reviewers found that there are multiple late complications of head and neck cancer and its treatment. Lymphedema and fibrosis are possible complications. Lymphedema may cause hoarseness, airway compromise, dysphagia or swelling, tightness and decreased range of motion of the neck with decreased function and pain. Risk factors include radiation treatment and neck dissection.  The treatments which have been shown to be beneficial include massage therapy/physical therapy with manual lymphatic drainage and complete decongestive therapy. In this case, the patient has received physical therapy, but the documentation does not support that he has failed treatment with manual lymphatic drainage and complete decongestive therapy. Furthermore, there is a lack of medical literature to support the efficacy of a fully programmable device used for pneumatic compression for the head and neck. Thus, the requested pneumatic compression garment is not likely to be of greater benefit than other treatment options.Final Result: The reviewers determined that the requested device 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  Three physician reviewers found that pharmacogenomics is the use of genetic polymorphisms to guide medication treatment decisions. A review of the literature shows there have been few rigorously conducted randomized clinical trials to assess the effectiveness of using pharmacogenomics for the treatment of major depressive disorder. A recent meta-analysis by Rosenblat and colleagues included four randomized controlled trials and two open-label cohort studies. The authors noted that there was overall an improved outcome (improved rates of response and remission) for the group that used pharmacogenomics to help guide treatment.  However, in all of the randomized controlled trials, the treating provider was not blinded. Additionally, the studies had other methodological flaws, and some were under-powered to show an effect. At the present time, there is insufficient evidence to support improved patient outcomes when pharmacogenomic data are used to guide medication selection for the treatment of major depressive disorder. Therefore, the superior effectiveness of genetic testing not been established. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewers 2 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewers 3 is board certified in clinical cytogenetics and genomics 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the blood test (advanced lipoprotein testing). Based on the records provided, the patient presented with some cardiovascular risk given her family history of heart disease. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established and are updated by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein associated phospholipase A2, sub-classifications of low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein (a), Apo A-1, CRP, hsCRP, insulin, fibrinogen, and homocysteine. Treatment changes or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Thus, the blood test (advanced lipoprotein testing) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the blood test (advanced lipoprotein testing) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing.  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease 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: An enrollee has requested reimbursement for skilled nursing facility (SNF) services. The records report that this patient presented with multiple fractures and was transferred to the SNF after undergoing a right hip hemi-arthroplasty. The enrollee has a right foot drop and fractures of the left acetabulum and right proximal humerus. The enrollee is unable to transfer or ambulate, and requires assistance with activities of daily living such as ambulating, toileting, and bed mobility. Furthermore, the enrollee has a Foley catheter and is incontinent of bowels. The provider noted a need to stay at the SNF. The patient continued to require skilled nursing and skilled rehabilitation services at least five days per week. Moreover, these services required the skills of technical or professional personnel such as nurses, physical therapists, and occupational therapists. Given these findings, the SNF services provided were medically necessary for treatment of this patients medical condition. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy. According to medical literature, medically necessary services are healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. In this case, the patient could benefit from early intervention services and speech and language therapy given the identified delays in both receptive and expressive language skills. Due to delays in expressive and receptive language skills, the requested speech therapy services are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychology and is a board certified behavioral analyst 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 magnetic resonance imaging of the shoulders. A study indicates that shoulder pain is the third most common musculoskeletal complaint in orthopedic practice. Shoulder pain is usually due to a defect of the rotator cuff and/or an impingement syndrome. Shoulder pain is a very common symptom. Disorders of the rotator cuff tendons due to wear or tear are among the most common causes of shoulder pain and disability. A SLAP (superior labral tear from anterior to posterior) lesion may also be present. Magnetic resonance imaging, magnetic resonance arthrography, and ultrasound are increasingly being used to assess the presence and size of rotator cuff tears to assist in planning surgical treatment. It is not known whether one imaging method is superior to any of the others. In this case there is a chronic history of shoulder pain. The patient depends upon their upper extremities as there is a history of paraplegia. The enrollees pain is not relieved by conservative treatment. As such, the need for imaging studies to determine proper treatment is clearly evident. In light of the foregoing, the request for magnetic resonance imaging of the shoulders is reasonable, appropriate, and medically necessary.Final Result: The reviewer determined that magnetic resonance imaging of the shoulders 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.