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

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage and continuation of acupuncture services for treatment of the enrollees chronic pain. Findings: The physician reviewer found that there is sufficient support for a portion of the services at issue.  In reviewing the records available, it does not appear that the patient had an acupuncture trial prior to the services at issue. Given that the patient continued to be symptomatic despite medications, an acupuncture trial for pain management and function improvement was medically appropriate and is supported by the peer-reviewed literature.  The medical evidence supports the initial trial of acupuncture services. However, current guidelines support additional care based on the functional improvements obtained with the trial.  In this patients case, no significant functional improvement was documented with the trial.  Thus, the medical necessity of continued acupuncture services has not been established.  All told, acupuncture services were medically necessary, but not thereafter.Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in oriental 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: An enrollee has requested radiofrequency neurolysis for treatment of the enrollees mid and lower back pain.  Findings: Two physician reviewers found that the request for radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is medical literature supporting the utility of thoracic facet radiofrequency neurolysis for the treatment of pain due to thoracic facet pain. Hegarty performed a 12-month retrospective observational evaluation of adults treated with radiofrequency (RF) for refractory sacroiliac joint syndrome (SIJ). The author states In conclusion this study identified that creating a consistent RF lesion between the sacral foramen and the SIJ will reliably and safely capture the innervation of the SIJ with significant long-term clinical improvement. Based on these results, we propose that the use of this technique should be considered sooner in the treatment of refractory SIJ syndrome. The patients history and physical exam is consistent with lumbar and thoracic facet pain. Additionally, the patient demonstrated thoracic facet pain for which radiofrequency ablation is an appropriate treatment. Therefore, based on current medical literature and the presented clinical records, radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested procedure 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: All three physician reviewers are board certified in anesthesiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Stelara injections for treatment of the enrollees palmar/plantar psoriasis. Findings: The physician reviewer found that  based on a combination of evidence and guidelines, the recommended therapy for treatment of this patients medical condition is treatment with non-steroidal anti-inflammatory drugs followed by disease-modifying antirheumatic drugs (DMARDs), if the disease is still active (Ritchlin, et al; Gossec, et al). In patients whose joint pain does not improve after three months of treatment with methotrexate (MTX), most recommend treatment with leflunomide. The current consensus among experts is that anti-tumor necrosis factor (TNF) inhibitors should be used after the failure of an adequate therapeutic trial of one traditional DMARD. The TNF agents that are approved for psoriatic arthritis are etanercept (Enbrel), adalimumab (Humira), infliximab, and golimumab.  In those psoriatic arthritis patients who do not respond to two different TNF inhibitors or have a contraindication to anti-TNF therapy, the use of ustekinumab (Stelara) is recommended. In this case, the patient has failed MTX due to elevated liver function tests. The medical literature recommends failure of two anti-TNF agents prior to trying another agent. She has tried Enbrel, a receptor antagonist, which was ineffective. However, the submitted records do not show that Humira, a humanized monoclonal antibody which blocks TNF, has been tried and failed. As such, Stelara is not medically indicated 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 internal medicine with sub-specialty certification in rheumatology 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 vein embolization and the related medical services for treatment of the enrollees pelvic congestion syndrome. Findings:  The 3 physician reviewers found that the request for vein embolization and the related medical services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patients symptoms correlate with the imaging findings that are consistent with pelvic congestion syndrome. Embolization of the gonadal vein to prevent reflux and pelvic pressure is an established treatment modality for this condition. The proposed plan is reasonable and appropriate in this clinical setting. Accordingly, the request for vein embolization and the related medical services has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 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 reviewer number one is board certified 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 two is board certified 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested Nutropin AQ Nuspin for treatment of the enrollees short stature. Findings: The physician reviewer found that the patients height is not more than two standard deviations below the mean for age and gender, there is no evidence of growth deceleration, and his bone age was normal. The patient has no known morphological abnormalities of the pituitary gland. The patients poor response to provocative growth hormone (GH) testing does not indicate that he is GH deficient, as only four serial blood samples were obtained over a period of 90 minutes for both provocative agents. Provocative testing has poor sensitivity and specificity for the diagnosis of GH deficiency, particularly in a male patient who has delayed pubertal development who is not primed with sex steroids. All told, the requested Nutropin AQ Nuspin 20 mg is not medically necessary for treatment of this patients medical condition.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 pediatrics with sub-specialty certification in pediatric 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: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for Otezla 30 mg tablet. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting. The provider had checked off a box to indicate alcohol use by this patient, but a visit report noted a negative history for alcohol use. However, even with alcohol use and not abuse, the requested medication is not medically necessary. There are alternative treatments that are appropriate for this patient. The medical literature supports the use of methotrexate or ultraviolet light therapy in the management of patients diagnosed with plaque psoriasis. In this patients case, there is no documented adverse effect or contraindication to the use of methotrexate or ultraviolet light therapy. As such, the requested medication Otezla 30 mg tablet is not medically indicated 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injection for treatment of the enrollee, who has been diagnosed with pelvic floor dysfunction.  Findings: Two physician reviewers found that in patients with dyssynergic defecation, ineffective defecation is associated with a failure to relax, or inappropriate contraction of, the puborectalis and external anal sphincter muscles.  This narrows the anorectal angle and increases the pressures of the anal canal so that evacuation is less effective.  The pathogenesis of dyssynergic defecation is not completely understood, but is probably multifactorial.  It is thought to be an acquired, learned dysfunction.  Manometry alone is insufficient for this diagnosis to be made, but is best made in conjunction with an abnormal balloon expulsion test.  Per the medical evidence, treatment consists of patient reassurance and the use of biofeedback. Additionally, stimulant or osmotic laxatives are given.  There is a lack of evidence that Botox injections are effective for treatment of this disorder.  In sum, Botox injection is not likely to be superior over other treatment options.Final Result: Two reviewers determined that the services at issue are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Xyrem for treatment of the enrollees narcolepsy.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Xyrem is the only U.S. Food and Drug Administration (FDA) approved medication for the treatment of narcolepsy with cataplexy. The records show a decreased mean sleep latency with two naps with REM sleep confirmed on polysomnogram that documented that the patient was not sleep deprived. Two naps with REM sleep in a patient with a reduced mean sleep latency confirms a diagnosis of narcolepsy. In addition, the patient has a history of cataplexy and severe daytime sleepiness. In this clinical setting, Xyrem has been established as medically necessary for treatment of the patients narcolepsy with cataplexy.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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: An enrollee has requested authorization and coverage for music therapy for treatment of the enrollees autism and obsessive compulsive disorder like symptoms. Findings:  The physician reviewer found that there is sufficient support in the peer-reviewed literature for the treatment of music therapy in this clinical setting. A single-center, parallel-group, randomized clinical trial of 30 patients with OCD who were randomly assigned to standard treatment (pharmacotherapy and cognitive-behavior therapy) plus 12 sessions of individual music therapy or standard treatment only for one month. The study found that music therapy resulted in a greater decrease in total obsessive score and was significantly more effective in reducing anxiety. The authors concluded that In patients with OCD, music therapy, as an adjunct to standard care, seems to be effective in reducing obsessions, as well as co-morbid anxiety and depressive symptoms. In addition, music therapy may help children with ASD to improve their skills in primary outcome areas that constitute the core of the condition including social interaction, verbal communication, initiating behaviour, and social-emotional reciprocity. Music therapy may also help to enhance non-verbal communication skills within the therapy context. Therefore, music therapy is medically necessary for treatment of the patients ASD and OCD like symptoms. Final Result: The reviewer determined that the requested therapy 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan performed.  Findings:  The physician reviewers found that Lyme disease is an infectious disease caused by bacteria generally transmitted by a tick bite. The most common symptom is an expanding area of redness at the site of the bite known as erythema migraines that often begins about a week following the bite. Other symptoms include fever, headache, joint pain, focal paresthesias, and unusual sites of paralysis. Overall, there is limited value in obtaining a SPECT scan for this patient since regardless of the findings since the ultimate management is primarily based on clinical presentation. All told, the SPECT scan performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the diagnostic procedure 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 s are board certified in diagnostic radiology and 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 Optune treatment for treatment of the enrollees glioblastoma. Findings: Three physician reviewers found that the Central nervous system (CNS) tumors are classified by the World Health Organization (WHO) based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV (Louis, et al; Kleihues, et al). Glioblastoma multiforme is a high grade tumor that is best treated with resection, radiation therapy, and chemotherapy. The standard of care is to resect the glioblastoma maximally followed by treatment with temozolomide. The U.S. Food and Drug Administration (FDA) approved Optune (formerly NovoTTF-100A) to deliver alternating electrical fields to treat recurrent glioblastoma. The National Comprehensive Cancer Network (NCCN) guidelines have now included this treatment option in their treatment flow charts and follow-up analyses have backed up the results on efficacy (Wong, et al). Recently, the FDA expanded the indication for Optune to include newly diagnosed glioblastoma when used along with temozolomide and radiation therapy. Given this support, the requested Optune treatment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three 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 reviewer number one is board certified in radiation oncology 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 internal medicine with sub-specialty certification in medical oncology 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 medical oncology and hematology 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 digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Two reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol is likely of greater benefit to this patient than two-dimensional imaging alone. Accordingly, the breast tomosynthesis is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue is 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: All three physician reviewers 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.