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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for clindamycin phosphate 1% gel daily. Epidermal inclusion cysts are common vulvar cutaneous lesions that are typically skin-colored dermal nodules ranging in size from a few millimeters to several centimeters in diameter. Infected, fluctuant cysts tend to be larger, more erythematous, and more painful than sterile inflamed cysts, which may resolve spontaneously without therapy but are prone to recurrence. Treatment options include excision or injection with steroids to hasten the resolution of inflammation, although treatment is not necessary unless desired by the patient. In this case, the patient has recurrent vulvar epidermal inclusion cysts. Although the patient underwent excision, the condition has recurred. Topical clindamycin is frequently prescribed for hidradenitis suppurativa (HS), and Clemmensen notes that in a study of 30 patients with recurrent HS, the overall effect of clindamycin treatment based on patients' assessments, number of abscesses, inflammatory nodules and pustules was significantly better than placebo at each monthly evaluation. Although frequently prescribed, data to support the efficacy of topical clindamycin is limited for the treatment of HS or other vulvar lesions. Given the lack of evidence and data in current medical literature to support the use of topical clindamycin in this clinical setting, the requested medication is not medically indicated. Therefore, clindamycin phosphate 1% gel daily is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 authorization and coverage for Ibrance capsules.Findings: Three out of three physician reviewers found that the requested medication, Ibrance  capsules, is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Ibrance (palbociclib) is FDA approved for the treatment of metastatic breast cancer in combination with fulvestrant or an aromatase inhibitor. Ibrance does not have off-label indications at this time. Low-grade serous ovarian cancers are known to respond to aromatase inhibitors. Based on this, there are two ongoing trials looking at CDK 4/6 inhibitors letrozole with ribociclib and fulvestrant with abemaciclib. A trial of palbociclib with and without trametinib showed poor activity. A case report involving combination therapy of palbociclib with letrozole has noted a continued response to treatment. In this case, however, the request is for single agent therapy. Under these circumstances, the requested medication is unlikely to be more beneficial than any available standard therapy. Therefore, the requested medication, Ibrance capsules, is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine, with subspecialty certifications in medical oncology and hematology, and are actively practicing. Physician reviewer 3 is board certified in internal medicine, with subspecialty certification in medical oncology, and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Korlym 300 mg tablet (3 times daily). In a systematic review of the literature on the role of mifepristone in the management of meningiomas, Cossu and colleagues concluded that no clear evidence existed to recommend mifepristone in inoperable meningiomas. The authors noted that while preliminary encouraging results were found in diffuse meningiomatosis, further multicenter placebo-controlled trials were required. Apra and colleagues report that current standard of care in the treatment of meningioma includes observation, surgery, and radiotherapy. The authors note that systematic therapies are not effective in general but that there are several ongoing clinical trials. Given that current medical literature does not recommend the use of mifepristone in the treatment of sella meningioma, the requested medication is investigational. Therefore, Korlym 300 mg tablet (3 times daily) is not likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Korlym 300 mg tablet (3 times daily) is not 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 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 reviewer 1 is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for OxyContin 30 mg three times a day. The Centers for Disease Control and Prevention (CDC) guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and nonopioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The American Society of Interventional Pain Physicians (ASIPP) guidelines recommend providers to establish physical diagnosis and assess pain levels and disability to support medical necessity of treatment with opioids. In this case, the patient has chronic pain involving multiple areas. The records document that the patient has been treated with multiple forms of opioid medications in the past with poor effect. The provider noted that the patients pain has been stable on OxyContin with effective pain relief rated as 2/10 from his baseline pain rated as 10/10. His urine toxicology and Controlled Substance Utilization Review and Evaluation System (CURES) reports have been consistent with his therapeutic regimen. Furthermore, the provider reported that there is no evidence of adverse drug reactions or aberrant behavior identified. The providers documentation is consistent with the guidelines from the CDC and ASIPP for the safe prescribing of opioid therapy. Given this support, the requested OxyContin 30 mg three times a day is 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 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.
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 custom foot orthotics. This patient is noted to have a history of painful plantar fasciitis, which was treated with plantar fasciotomy and eventually returned. She has been advised to stretch her plantar fascia daily, wear supportive shoes, and be fitted with custom foot orthotics. Custom foot orthotics have been utilized successfully for the treatment of plantar fasciitis and are within the current standard of care in this clinical setting. Researchers reported that 85-90% of patients with plantar fasciitis can be managed without surgery. The authors noted that, A wide variety of orthosis options are available for the management of plantar fasciitis. The use of shoe inserts (e.g., silicone heel pads, felt pads, and rubber heel cups) in combination with stretching exercises has been shown to provide superior short-term improvement in heel pain compared with stretching alone. Based on the documentation provided, this patient has continued arch pain even after plantar fasciotomy and she continues to perform stretching of the plantar fascia. There is evidence that addition of orthosis in the shoe can provide additional benefit. For these reasons, requested bilateral custom foot orthotics are medically necessary for treatment of this patient.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 a licensed D.P.M., 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 patients parent has requested authorization and coverage for weekly individual therapy. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 2. The patient had some risk of harm, due to recent concerning behavior online. The records did not indicate suicidal or homicidal ideation.In terms of functional status, the records support a score of 2. The documentation noted that the patient was high functioning academically with good social skills. The patients functioning was somewhat compromised due to symptoms of social anxiety and panic. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to the presence of some depressive symptoms. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a mildly stressful environment due to her parents being divorced and splitting her time between the households, and some struggles with her stepfather.With regard to level of support of the recovery environment, the records support a score of 2 due to her parents efforts to arrange treatment for patient and their participation in treatment. In terms of resiliency and treatment history, the records support a score of 2. The patient had significant resiliency and/or response to treatment as she reported stopping concerning online behavior and positive self-esteem. With regard to treatment acceptance and engagement, the records support a score of 2. The patient demonstrated constructive engagement. Thus, the patient has a total score of 15. In this case, the recommended level of care is low intensity community-based services. This is consistent with the level of care that the patient is requesting. Therefore, weekly individual therapy is medically necessary for the treatment of this patient. 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly individual therapy services in 50-minute format. The American Psychiatric Association (APA) practice guidelines for the treatment of major depressive disorder recommend medication management by a psychiatrist along with weekly individual or group psychotherapy when possible. In this case, the patient has a history of major depressive disorder. Her medication management is being handled by her primary care physician, and the patient declined medication trials recommended by her psychiatrist. The patient was being seen by an outside provider for weekly individual therapy services without psychopharmacologic medication management. In this clinical setting, weekly individual psychotherapy services in conjunction with ongoing psychopharmacologic management by a psychiatrist is standard of care. While the patient has refused psychopharmacologic management and is on psychotherapy alone, the requested services are medically indicated. Therefore, weekly individual therapy services in 50-minute format are medically necessary for the treatment of this patient.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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet-rich plasma (PRP) injections for the right knee. This patient sustained a right knee injury and was diagnosed with a grade 3 medial collateral ligament (MCL) tear, anterior cruciate ligament (ACL) tear, medial meniscus tear, and lateral meniscus tear. She underwent ACL reconstruction with medial and lateral meniscus repair. Surgical augmentation with PRP was given as the MCL and meniscal capsular junction were not repaired surgically. A subsequent PRP injection was performed to the posterior lateral corner ligaments including popliteus, arcuate ligament, popliteal fibular ligament, and fibular collateral ligament. Researchers indicated that despite a lack of consensus regarding PRP indications and efficacy, there are widespread applications of this treatment for various musculoskeletal injuries. Researches concluded that there is a growing body of evidence to support PRP for selected indications in osteoarthritis, ligament, tendon and meniscal injuries of the knee.Researchers reported that abundant high-quality evidence supports the use of leukocyte-poor PRP for osteoarthritis of the knee. Researchers found complete clinical and magnetic resonance imaging (MRI) documented healing of the MCL post injection of autologous PRP for refractory pain after low-grade MCL injury. Given this support, the PRP injections for the right knee were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the PRP injections for the right knee were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein blood testing (CPT 83704, 82172, 83695 and 83698) performed by Quest Diagnostics. Harada and colleagues report that standard lipid testing, represented by total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides, is a well-established platform for cardiovascular disease (CVD) risk prediction and management. In this case, laboratory testing reported a total cholesterol level of 222 mg/dL, HDL-C of 72 mg/dL, LDL-C of 135 mg/dL, and triglyceride level of 61 mg/dL. Visit notes did not report a history of diabetes, hypertension, or tobacco use. While an advanced lipid profile may be used as adjunctive information in determining whether to start a patient with intermediate CVD risk on statin therapy, given this patients low overall CVD risk, current guidelines recommend continued lifestyle modifications and would not consider the patient a candidate for statin therapy. Therefore, advanced lipoprotein blood testing (CPT 83704, 82172, 83695 and 83698) that was performed by Quest Diagnostics was not likely to have been more beneficial for the evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the advanced lipoprotein blood testing (CPT 83704, 82172, 83695 and 83698) performed by Quest Diagnostics was not likely to have been more beneficial for the evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue not likely to be more beneficial for the 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 internal medicine with sub-specialty certification in cardiovascular disease 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 Circulating Tumor DNA test. The treatment of advanced non-small cell lung cancer has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in certain adenocarcinomas. The Guardant360 test is commonly referred to as a liquid biopsy since it involves sampling of tumor cells that may be circulating in the peripheral blood. Current data reports that the Guardant360 assay can analyze up to 70 genes for mutations.Guardant360 is known for high specificity, but low sensitivity. According to the NCCN guidelines, the Guardant360 test is associated with false negative rates of up to 30%. The NCCN guidelines support limited use of Guardant360 for patients who are unfit to pursue more invasive methods for tumor sampling. The Guardant360 test was reasonable for this patient since the disease was inaccessible without subjecting the patient to a highly invasive procedure. In conclusion, the Guardant360 Circulating Tumor DNA test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the Guardant360 Circulating Tumor DNA test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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.