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

The enrollee requested Oncotype DX prostate testing for prostate cancer. The surgical pathology report showed adenocarcinoma, Gleason score 6. Per the genomic prostate score (GPS) report, the patients GPS score was 8, indicating very low risk, and his prostate specific antigen (PSA) level was 8.3 ng/mL. Per documentation, the patients physician ordered the test to identify the specific risk of aggressive prostate cancer. The physician indicates this information allows for a more informed decision between active surveillance and immediate intervention. The Oncotype DX Prostate Cancer Assay may be utilized to counsel men regarding the best course of therapy (active surveillance vs. treatment) in newly diagnosed low or low-intermediate prostate cancer. However, studies regarding the efficacy of this testing are recently published and need continued validation from widespread clinical use. In addition, it is difficult to ascribe clinical utility of Oncotype DX prostate testing in patients planning to undergo active surveillance as all patients in the studies, regardless of clinical criteria, elected radical prostatectomy within six months of diagnostic biopsy. Moreover, the validity of using different degrees of tumor pathology as markers to estimate the risk of progression of a tumor in the body is unclear. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in urology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for a cervical spine magnetic resonance imaging (MRI). The enrollee has cervical degenerative disc disease (DDD), upper back pain, pain in the left shoulder, and cervical spinal stenosis. He has a history of radiofrequency ablation on multiple levels. A magnetic resonance imaging (MRI) scan several years ago showed evidence of spinal stenosis, questionable myelopathy of the cervical spine at the C3/C4 and the C6/C7 level; and degenerative disc disease (DDD) at the C5/C6 level. A visit note indicates the enrollee was seen for chronic neck and base of skull pain. He also has left shoulder pain. On examination, strength was 5/5 to the upper and lower extremities.  There were no sensory deficits to light touch, pinprick or vibration.  Deep tendon reflexes were 2+.  The treatment plan included an MRI of the cervical spine.  Review of the medical literature indicates an MRI of the cervical spine is indicated if there is pain localized to the neck or of a radicular nature that is subacute or chronic with failure to improve after six or more weeks of non-operative treatment and the enrollee is being considered for invasive treatment and there is significant interference with daily function. Conditions, such as obtunded or temporary non-assessable status, polytrauma, and neurologic deficit are predisposing factors for injuries discovered on an MRI but missed on computed tomographic scan alone. These findings can affect the management of acute cervical spine fractures.  MRI can diagnose intrinsic spinal cord injuries. In this case, no clear, significant trauma concerning for fracture or hematoma is evident. The medical literature indicates an MRI of the cervical spine is indicated if there is pain localized to the neck or radicular in nature; the pain is subacute or chronic, with failure to improve after six or more weeks of conservative treatment; the patient is being considered for invasive treatment; and there is significant interference with daily function. The record indicates the enrollee has complaints of pain to the neck and to the base of the skull.  However, there is insufficient evidence in the record of the enrollee completing a conservative treatment course of six weeks or more.  Notes do not indicate the enrollee is being considered for invasive treatment or there is significant interference with daily function.  There are no specific deficits noted on the physical examination.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurological 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The enrollee requested reimbursement for the Oncotype DX Genomic Prostate Score test for prostate cancer. The biopsy report showed adenocarcinoma, acinar type with a Gleason score of 6 (3+3) and a grade group of 1. The enrollees Genomic Prostate Score (GPS) score was 24, which denotes very low risk, and his prostate specific antigen (PSA) level was 7.1 ng/mL. The enrollees physician ordered the test to identify his specific risk of aggressive prostate cancer in order to make a more informed decision between active surveillance and immediate intervention. His physician indicates the GPS can identify those who need immediate surgery or radiation therapy versus those who can confidently choose active surveillance. The physician spoke with the enrollee specifically about the option of active surveillance and the enrollee understood it was a treatment option best suited for people with very low and low risk disease.  The enrollee underwent the recommended testing and was noted to be considered a very low risk. The Oncotype DX Prostate Cancer Assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS). A lower GPS score indicates more favorable biology and less aggressive disease. Guidelines for prostate cancer indicate several tissue-based molecular assays have been developed in an effort to improve decision-making in newly diagnosed men considering active surveillance and in treated men considering adjuvant therapy or treatment for recurrence. However, there is limited data on clinical outcomes to support routine use of Oncotype DX. Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. A guideline on active surveillance of prostate cancer indicates use of ancillary tests beyond digital rectal exam, prostate specific antigen, and biopsy to improve enrollee selection or as part of monitoring in an active surveillance regimen remains investigational. Peer-reviewed studies do not show this test can help to know whether the cancer will return or change treatment decisions and improve subsequent outcomes. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in urology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for sleep safe bed II. The records document that this patient has a genetic mutation that has resulted in a developmental disability with optic atrophy, abnormal central nervous system development and global developmental delay complicated by a seizure disorder. His formal medical diagnosis is Bosch-Boonstra-Schaaf optic atrophy. Key to this diagnosis is abnormal sleep with the frequent occurrence of postural changes that result in a high potential for musculoskeletal injury. Among the most salient features of this syndrome are disordered sleep with severely impaired vision. This condition renders the patient at risk for significant musculoskeletal injuries that require a bed that fully encloses the patient in a safe environment. No adaptation of a conventional bed will circumvent the potential for self-harm to this patient. Thus, the requested sleep safe bed II is medically necessary for 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 board certified in neurology with special qualification in child neurology 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 reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying the LOCUS guidelines, this patient does not meet the criteria for IOP services. The patient presented with no risk of harm (score 1) due to a lack of current suicidal ideation, aggression or self-harm behaviors. The progress notes do not indicate that the patient has demonstrated any suicidal or homicidal ideation or psychosis. He presented with some anxiety and depression symptoms in regards to his eating disorder but most of the time he has been noted to have a euthymic mood. The patient has demonstrated mild functional impairment (score 2) given his overall ability to function and participate in treatment. The patient presented with minor comorbidities (score 2) due to the presence of obesity, overall medical stability, and no substance use issues. There was no indication of significant unstable or uncontrolled medical issues. He had not engaged in any substance abuse according to the records. The patients recovery environment is described as mildly stressful (score 2) considering his stable living environment and his recovery environment is supportive (score 2). The patients treatment response has been significant (score 2). The provider noted that the patient has been open in treatment and receptive to feedback from his providers and group members during group therapy. The providers noted that the patients mood has stabilized and there is a lack of any acute behavioral health symptoms. However, the patient has continued to gain weight. The patient has been constructive in IOP (score 2) due to good cooperation in treatment. This gives the patients presentation a composite score of 13, which score correlates with low intensity community based services. All told, the IOP services rendered were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement, and authorization and coverage for a CPAP machine. The enrollee has a history of obesity, with a body mass index of 34.45 and obstructive sleep apnea (OSA). At a follow up visit with his pulmonologist for hypersomnia, the enrollee indicates he feels better when he uses the CPAP machine all night, but he has problems with his CPAP mask. Physical exam showed a small blister on the left side of the bridge of the enrollees nose, so a referral for mask fitting by respiratory therapist was made. The enrollee indicates his compliance with more regular CPAP use has been affected because of the facial blister caused by the CPAP mask. Clinical practice guidelines strongly recommend the use of positive airway pressure (PAP), compared to no therapy, to treat obstructive sleep apnea (OSA) in adults with excessive sleepiness. The guidelines also recommend adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data to ensure adequate treatment and adherence, at PAP therapy initiation and during treatment of OSA. Consistent with the enrollees facial blister, literature indicates nasal skin lesions, including erythema, and ulcers at the site of mask contact, increases with longer CPAP durations, and is a common adverse effect that discourages enrollee compliance to CPAP use. As a result, the literature indicates the choice and application of the CPAP mask in patients with OSA is a challenge that greatly affects long-term compliance to PAP therapy. As per a study in the medical literature, the best mask is the one the enrollee will wear. It is unclear which type of CPAP mask the enrollee currently uses. However, regardless of the type, the enrollees record indicates non-compliance with CPAP use is because of the mask fitting. Current guidelines strongly recommend CPAP use for patients with OSA and hypersomnia, as is the case with this enrollee.Final Result: The reviewer determined that the requested services were and are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is licensed in sleep 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services.  Applying the CALOCUS guideline, this patient met the medical necessity criteria for IOP level of care. The patient was at moderate risk of harm (score 3) given her suicidal ideation, emotion-driven binge eating, and unintentional self-harm by hitting her head and scratching her face. The patient demonstrated moderate functional impairment (score 3) considering her inability to perform ADLs including self-care. The patient presented with comorbid depression, anxiety, and borderline personality disorder (score 3). The patients recovery environment was moderately stressful (score 3). She reported social alienation from her peers. The patients recovery environment was supportive (score 1). The patient showed partial response in prior treatment (score 3) and during this IOP admission. The patient was constructive in treatment (score 2). Her parent was optimally involved in her care and worked actively with the patients providers (score 1). This gives the patient a composite score of 19, which is consistent with medically monitored community based services. Given the severity of the patients illness, the IOP services were medically necessary for treatment of this patient. 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 psychiatry with expertise 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for Wilderness Therapy services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Applying CALOCUS, the Wilderness Therapy services were not medically necessary for treatment of this patient. There was no indication that the patient was aggressive at any time during treatment. The patient did have a history of substance use that affected his primary psychiatric issues. The patient did not express any symptoms of psychosis. There was no indication the patient had any medical issues affecting treatment. Given these findings, the Wilderness Therapy services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 psychiatry with subspecialty 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Xifaxan (rifaximin) 550 mg three times per day for 21 days, or in the alternative, any duration of treatment with Xifaxan 550 mg three times per day. The records provided for review demonstrate that this patient has SIBO. Xifaxan has proven highly effective in SIBO for eradication of bacteria and symptom relief. Studies have shown that Xifaxan is more effective with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, fluoroquinolones, and penicillin. The dose and duration of 550 mg three times daily for 14 days is consistent with regimens used in studies, which vary widely, but are generally 7, 10, or 14 days in duration. For these reasons, the use of Xifaxan 550 three times daily for 14 days is medically necessary for the treatment of this patients SIBO. Final Result: The reviewer determined that a portion of the requested medication regimen is 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 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

The patient has requested authorization and coverage for Xifaxan 550 mg twice daily for 14 days. The records provided for review demonstrate that this patient has SIBO with symptoms of gas and abdominal bloating. Xifaxan is highly effective in SIBO for eradication of bacteria and symptom relief. Xifaxan demonstrated greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, fluoroquinolones, and penicillin. The Xifaxan dose and duration of 550 mg twice daily for 14 days is consistent with regimens used in studies. For these reasons, the use of Xifaxan 550 twice daily for 14 days is medically necessary for the treatment of this patients SIBO.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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for a spinal cord stimulator trial. There are is a lack of large randomized controlled studies establishing the efficacy of spinal and dorsal root ganglion stimulation for type 2 trigeminal neuralgia. However, there are studies that have demonstrated that spinal cord stimulation allows patients with trigeminal neuralgia to experience pain reduction and improved quality of life. Based on the analysis of this patients treatment history with extensive oral neuromodulators, multiple surgical interventions, and gamma surgery ablation, she has a case of a refractory trigeminal neuralgia. A trial with spinal cord stimulation is appropriate for refractory trigeminal neuralgia and can make a substantial difference in terms of chronic pain reduction. A retrospective case series found that 75% of implanted patients continued to derive benefit for up to 10 years after implantation. A recent retrospective single-center series of 12 patients with trigeminal neuropathy were treated with upper cervical spinal cord stimulation reported an average of 57.1% pain reduction with this treatment modality. All told, a spinal cord stimulator trial is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested spinal cord stimulator trial is 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology 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.